VASCULAR SURGERY

NOTES VESAP 4
 Basic science  Cerebrovascular
 Cerebrovascular  Upper extremity
 Upper extremity  Dialysis access
 Aortic and iliac  Aortic and iliac
 Renal and mesenteric  Renal and mesenteric
 Lower extremity  Lower extremity
 Venous and lymphatic  Venous and lymphatic
 Dialysis access  Vascular medicine
 Vascular medicine  Vascular diagnosis
 Vascular imaging  Radiation safety
 Radiation safety
 Critical care PPT FOLDERS
 Miscellaneous  Basic science
 Vascular imaging
 Cerebrovascular
 Aortic & iliac
*best conduit in children is hypogastric  Renal & mesenteric
 Upper extremity
 Lower extremity
 Dialysis access
 Venous & lymphatic
 Miscellaneous

RUTHERFORD
 Ch 90 - Technique: EVAR
…

PFIZER
 Hematology
 Critical care
 Cardiac surgery
 Thoracic surgery
 Vascular surgery

SABISTON
 Congenital heart disease
 Acquired heart disease - coronary insufficiency
 Acquired heart disease - valvular
 Thoracic vasculature
 Cerebrovascular disease
 Aneurysmal disease
 Peripheral arterial occlusive disease
 Vascular trauma
 Venous disease
 Lymphatics
 Access and ports
 BASIC SCIENCE
ANATOMY

Arterial wall
 tunica intima - endothelial cells, connective tissue, elastic tissue
 tunica media - ECM with smooth m. cells
 tunica adventitia - includes autonomic innervation and vasa vasorum

PHYSIOLOGY / RESPONSE TO INJURY

Two regulatory systems control smooth m.

 endothelium  influences tone and growth of underlying smooth m. via inhibitory and stimulatory factors released in
response to blood flow, O2 tension, hormones, cyto/chemokines
 autonomic innervation  responds to activation of peripheral baroreceptors, chemoreceptors, temperature receptors

Endothelium relaxing factors

 NO   adhesion and coagulation of blood elements on surface,  contraction of underlying smooth m.
 prostacyclin   platelet adhesion and aggregation,  smooth m. proliferation and migration,  vasodilation

Endothelium contracting factors

 thromboxane  opposite effects of prostacyclin
 endothelin-1  potent vasoconstrictor, antagonizes actions of NO

RESPONSE TO INJURY

Endothelial dysfunction
 is the initiating step in atherosclerosis
 mechanical or biochemical factors (ie, free radicals from abnormal lipid metabolism, carbon monoxide, tobacco)
 balance of factors shifts from  to  contraction, proliferation, migration of underlying smooth m. cells into intima
 also  adhesion of platelets, leukocytes, monocytes

Endothelium as mechanosensors
 two hemodynamic forces affect endothelial cells
- shear stress  frictional force at interface of endothelial surface and circulating blood
- pressure  circumferential deformation of blood vessels acting perpendicular to vessel wall

Response to shear stress

 ******

Cell-derived microvesicles

Re-endothelialization

Re-vascularization
 BASIC SCIENCE
HEMOSTASIS
 PHARMACOLOGY
Anticoagulation

Thrombolysis

Antiplatelet

Hyperlipidemia

Diabetes

Smoking cessation

Anti-hypertensive

Anti-arrhythmic

Pressors, inotropes
 PHARMACOLOGY

ANTICOAGULANTS

Form Dose Onset T½ Metabolism Reversal

ATIII activator
unfractionated heparin IV, SC protamine
low molecular weight heparin
enoxaparin (Lovenox) SC protamine
dalteparin (Fragmin) SC protamine
vitamin K antagonist
warfarin (Coumadin) PO 2.5-10 mg 24 h 20-60 h vit K, PCC, F7
direct factor Xa inhibitors
rivaroxaban (Xarelto) PO PCC, F7
apixaban (Eliquis) PO PCC, F7
fondaparinux (Arixtra) SC HD
direct thrombin inhibitor
dabigatran (Pradaxa) PO PCC, F7, HD
argatroban IV liver
bivalirudin IV kidney

 unfractionated heparin
- binds and enhances ATIII  inhibits FIIa and Xa  stabilize but does not lyse clot
- use in pts with severe renal insufficiency (GFR < 30)
- monitor PTT
 low molecular weight heparin (LMWH)
- mixture of smaller molecules   affinity of neutralizing cells/proteins to bind with them  eliminates dose-
dependent mechanism of action of unfractionated heparin
» 90% bioavailability after subcutaneous injection 
- metabolized by kidneys
-  risk for HIT but still possible
 warfarin (Coumadin)
- vitamin K antagonist ( F II, VII, IX, X, proteins C, S)
- monitor PT
 apixaban (Eliquis) is contraindicated in pts with severe liver disease 
 argatroban  falsely elevates INR, so if bridging to warfarin use INR goal > 4

prothrombin complex concentrate (PCC)

THROMBOLYTICS

Tissue plasminogen activator (tPA)

 produced by endothelial cells (mainly), vascular smooth muscle cells, fibroblasts
- most circulates bound in complex form with plasminogen activator inhibitor-1 (PAI-1)
- unbound form has T½ of 2-3 minutes

ANTIPLATELETS

Form Dose Onset T½ Metabolism Reversal

COX inhibitor
aspirin PO
ADP (P2Y12) receptor antagonists
clopidogrel (Plavix) PO
 PHARMACOLOGY
prasugrel (Effient) PO
ticlodipine (Ticlid) PO
ticagrelor (Brilinta) PO
PDE inhibitor
cilostazol (Pletal) PO
GpIIb/IIIa inhibitors
abciximab (ReoPro) IV
eptifibatide (Integrilin) IV
tirofiban (Aggrastat) IV
adenosine re-uptake inhibitors
dipyridamole (Persantine) PO, IV
dipyridamole/ASA (Aggrenox) PO

 clopidogrel (Plavix)
- ADP receptor inhibitor  prevents PLT crosslinking
- does not break up existing clots
 cilostazol (Pletal)
- inhibits PLT aggregation and causes vasodilation
- sometimes used to tx chronic claudication; no role in acute limb ischemia
- PDEs are contraindicated in pts with heart failure

 pentoxifylline  improves wound healing?

- ***

bupropion
 1st line pharmacologic tx for smoking cessation
 VASCULAR MEDICINE
VESAP 

COMPLICATIONS

Heparin-induced thrombocytopenia (HIT)

 lab testing
- #26
 associated risks
- low risk for bleeding unless plts drop below 10,000
- high risk for thrombosis up to 4 weeks after heparin is discontinued 
» arterial thrombosis is more common than venous in vascular patients
 management
- discontinue all heparin products
- use argatroban or bivalirudin (direct thrombin inhibitors)

Warfarin-induced skin necrosis

 pts with protein C deficiency  warfarin induces transient hypercoagulable state because of shorter T½ of protein C
 skin necrosis, most commonly in breasts, butt, thighs, penis

Hypofibrinogenemia
 complication of lytic therapy
 fibrinogen < 100 mg/dl
- immediately stop lytic agent
- if further   reverse coagulopathy with cryoprecipitate 

Factor V Leiden mutation

 most common hereditary cause of VTE
 initial tx of acute DVT in heterozygotes is same as general population

Pregnancy  pro-thrombotic state

 hormone-related induction of clotting factors
 anatomic compression of L iliac vein by gravid uterus

von Willebrand disease

 most common genetic bleeding disorder
 peri-op tx  intermediate purity vWF and FVIII

Hyperhomocysteinemia
 leads to premature arterial disease in children
 commonly associated with MTHFR mutation
 2-8x risk for MI or stroke, higher in F vs M
 normalization of homocysteine doesn't  risk of VTE and peripheral arterial thrombosis despite appropriate tx 

Cigarette smoking
 endothelial damage and altered function
  platelet adhesion and permeability of endothelial surfaces to fibrinogen
  NO availability and impairs vascular tone
 VASCULAR MEDICINE

Alcohol withdrawal syndrome

 peaks on day 3-5
 may develop delirium tremens, grand mal seizures
- delirium tremens  fever, tachycardia, hypertension, tremors, diaphoresis, hallucinations, disorientation,
agitation, urinary incontinence
 at-risk pts should be given prophylactic doses of benzodiazepines 

RISK ASSESSMENT

Revised Cardiac Risk Index (RCRI)

 estimates peri-operative cardiac events in pts undergoing non-cardiac surgery
 six independent predictors of major complications
- high-risk surgery (vascular surgery, open intraperitoneal or intrathoracic surgery)
- history of ischemic heart disease
- history of heart failure
- history of cerebrovascular disease
- insulin dependent DM
- pre-op Cr > 2

Carotid = moderate risk surgery 

 VASCULAR IMAGING
***

Brain MRI with diffusion-weighted imaging (DWI) is most Sn and Sp imaging technique for acute infarction 

Venous US

^ shows acute thrombosis of GSV and chronic thrombotic disease of femoral vein 
VASCULAR DIAGNOSIS
CEREBROVASCULAR
 CEREBROVASCULAR
CAROTID

Carotid artery stenosis (CAS)

 time to intervention after stroke/TIA is strongest determinant of stroke or death
- early carotid endarterectomy, ie, when neurologic and clinical condition have stabilized
» within 2 days  stroke and death rate 11.5%
» within 3-7 days  3.6%
» within 8-14 days  4%
» within 15-180 days  5.4%
- pts who remain hemiplegic are usually not candidates for intervention
 intracranial tandem ICA siphon lesion
- tx carotid bulb dz first, then optimal medical management, then tx intracranial lesion only if sx persist
 stump syndrome
- chronic ICA occlusion and ipsilateral focal neurologic symptoms
» microemboli arise from stump of occluded ICA or ipsilateral ECA that can pass into MCA due to patent ECA-
ICA anastomotic channels
- tx with endarterectomy of CCA and ECA with transection of ICA (to eliminate potential embolic source) and patch
angioplasty
- best results in pts with monocular amaurosis fugax
 concomitant/incidental ICA aneurysm
- tx separately based on their own guidelines
- tx aneurysm first if ≥ 8 mm
 asymptomatic CAS in pt with renal failure on HD  no intervention 
- pts on HD have high perioperative and long-term stroke and death rates after carotid intervention for
asymptomatic stenosis
- age > 70 and > 2 years on HD are predictive of death
- renal transplant is protective
 external carotid stenosis
- external CEA can be therapeutic in pt with hemispheric sx and ipsilateral ICA occlusion
- ECA can serve as important collateral
- can also be a source of embolization to ophthalmic artery via collaterals
- important to transect and oversew the proximal stump of ipsilateral ICA

Carotid endarterectomy (CEA)

 maneuvers for distal carotid artery exposure (ie, for high ICA bifurcation)
- medial mobilization of hypoglossal nerve -- first and easiest step
- division of posterior belly of digastric muscle (risk for glossopharyngeal injury, posterior to muscle)
- resection of styloid process
- anterior subluxation of mandible
- nasotracheal intubation
 eversion technique  ideal for pts with coils and kinks of ICA because ICA can be resected or moved down on the
common carotid
 cerebral perfusion monitoring during CEA
- awake neurologic observation (most reliable)
- carotid stump back pressure (> 40 indicates adequate perfusion)
- EEG monitoring
- sensory evoke potentials
 bradycardia during CEA
- carotid sinus
» located at carotid bifurcation
 CEREBROVASCULAR
» has baroreceptors that produce bradycardia and hypotension when stimulated by increased pressure or
surgical manipulation
» innervated by carotid sinus nerve (of Hering) which arises from glossopharyngeal nerve
- give atropine or other anticholinergic drug as initial treatment
- some surgeons routinely inject 1-2 cc of lidocaine near sinus to prevent or treat bradycardia
- vasopressors may be required for persistent hypotension

CEA post-op complications

 cerebral hyperperfusion syndrome
- manifests as severe ipsilateral headache and hypertension after CEA
- risk factors
» uncontrolled hypertension (goal < 140/80)
» CEA for high-grade symptomatic stenosis
» contralateral high-grade stenosis or occlusion or hx of CEA
› 14.3% incidence when staged CEAs were less than 3 months apart compared to 0% when interval was
greater
» urgent operation
» recent ipsilateral stroke
- high mortality (~38%)
- management  non-contrast CT and aggressive BP control in ICU
 cranial nerve injuries - occurs in 5-20% of CEAs
- marginal mandibular branch of facial nerve  ipsilateral drooping of corner of mouth
» typically result of cephalad retraction on mandible (not clamp injury)
- glossopharyngeal nerve  can lead to persistent pulmonary aspiration; pts often need feeding tube
» typically occurs during division of posterior belly of digastric muscle
- vagus nerve  unilateral vocal cord paralysis and hoarseness
- hypoglossal nerve  ipsilateral tongue deviation
 ICA dissection
- may be due to shunt placement or a flap at the endarterectomy endpoint
- reclamping and revising flap at distal endpoint would be appropriate unless it is too distal to reach, then can use
endovascular stent instead
- don't use anticoagulation in setting of fresh CEA

Carotid shunt
 used to maintain cerebral perfusion during CEA
 indications
- cases in which circle of Willis is not intact, ie, contralateral carotid occlusion
- pts with recent ischemic event will have an area of ischemic penumbra which benefits from increased perfusion
pressure
 additional methods to evaluate role of shunting
- transcranial Doppler
- sensory evoke potentials
- cerebral oximetry
 hx of contralateral stroke alone is not a general indication for shunt placement

Early ischemic stroke management (AHA 2015 guidelines)

 IV lytic therapy up to 4.5 hours after onset of symptoms
- tPA 0.9 mg/kg (max dose 90 mg IV)
- should be given even if endovascular tx is being considered
 CEREBROVASCULAR

CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial)

 largest randomized controlled trial comparing CEA and stenting
 found no significant difference in a composite outcome of stroke, MI, and death (hazard ratio 1.11; 95%CI 0.81-1.51)
 lower rates of complications in both groups than observed in previous trials
 supported both procedures as safe and effective treatment options
- results have been attributed to highly trained interventionists involved in study, limits external validity
 rate of periprocedural stroke was higher in the stenting group while the rate of MI was higher in the CEA group
 conclusion  no definitive superior treatment for CAS and tx decisions should be individualized to patients'
characteristics and needs

ACAS (Asymptomatic Carotid Atherosclerosis Study)

 objective was to determine whether the addition of CEA to aggressive medical management can  incidence of
cerebral infarction in patients with asymptomatic CAS
 multicenter study of 1600 pts with asx carotid stenosis ≥ 60%, randomized to medical management vs. medical
management and CEA
 stroke and death risk at 5 years  by 5.9% (5.1% vs. 11%)
 conclusion  pts with asymptomatic carotid artery stenosis ≥ 60% whose general health makes them good candidates
for elective surgery will have a  5-yr risk of ipsilateral stroke if CEA performed with < 3% perioperative morbidity and
mortality (added to aggressive management of modifiable risk factors)
 reproduced by European randomized study, the Asymptomatic Carotid Surgery Trial (ACST)

NASCET (North American Symptomatic Carotid Endarterectomy Trial)

 1400 patients
 showed a significant benefit for CEA for pts with symptomatic carotid stenosis > 50%, compared to medical
management alone
 pts with stenosis > 70% had 17% risk reduction for stroke at 2 years which persisted at 8 yr follow up
 conclusions
- overall rate of perioperative stroke and death was 6.5%, but rate of permanently disabling stroke and death was
only 2.0%
- other surgical complications were rarely clinically important
- CEA is a durable procedure

GALA
 prospective European multicenter randomized study with 3526 patients
 50% underwent CEA with local anesthesia vs. 50% under general anesthesia
 no significant difference in incidence of primary outcome of stroke, death, or MI at 30 days
- 4.5% for local vs. 4.8% for general
 main benefit for local anesthesia is neurologic monitoring during surgery and selective shunting

WARSS (Warfarin Aspirin Recurrent Stroke Study)

 no difference between aspirin alone and warfarin alone in preventing recurrent ischemic stroke or death in 2-yr
period

CHANCE (Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events)

 in first 90 days after stroke, there was significant reduction in recurrent stroke
- 8.2% in pts given clopidogrel and aspirin
- 11.7% in pts given aspirin alone
 CEREBROVASCULAR

Fibromuscular dysplasia of ICA

 classified by layer of vessel wall involved
- medial fibroplasia - most common
» classically occurs in middle-aged women
» results in multiple short stenoses of distal ICA with areas of aneurysmal dilation ("string of beads")
» management
› antiplatelet therapy
› further intervention if medical therapy fails  angioplasty alone
› avoid stenting unless there is an associated aneurysm or dissection
- intimal fibroplasia, medial hyperplasia - commonly appear as single, concentric stenosis or long tapering stenosis
of renal and internal carotid arteries
- adventitial hyperplasia - very rare and usually seen in localized stenosis
- perimedial dysplasia - commonly affects renal arteries and is associated with macroaneurysms

Iatrogenic carotid injury (ie, arterial line/sheath placement)

 CTA prior to intervention to identify presence and extent of any thrombus adherent to catheter
 if 6 Fr or smaller and recognized early  pull and hold pressure
 if 7 Fr or larger  cut down and open repair (endovascular tx if exposure would be too difficult)
 closure device is off-label and not ideal given likelihood of atherosclerosis

Carotid artery dissection

 classic presentation  facial pain, headache, partial Horner syndrome
 typically occurs several centimeters distal to bifurcation
 risk for ischemic stroke and recurrent dissection is highest in days to weeks following initial dissection event (25%)
 stroke can be result of thromboembolization (more common) or acute dissection extending into ICA
 management
- prevent stroke with anti-thrombotic agent
- endovascular or surgical tx is reserved for small minority of cases who progress with cerebrovascular events
despite optimal medical tx
 extension of acute type A aortic dissection
- increase in stroke rate at time of presentation but no difference after acute event (compared to those with
dissection confined to arch alone)
- medical tx (antiplatelet or anticoagulation) if asymptomatic
 traumatic carotid dissection
- mainstay for treatment is anticoagulation
» antiplatelet and systemic anticoagulation have been proven to be effective
» consider aspirin if heparin gtt is relatively contraindicated (ie, associated injuries like liver lac or SDH)
- endovascular or operative intervention may be considered if pt has a neurologic deficit, especially if fluctuating

Extracranial carotid artery aneurysm (ECAA)

 poor prognosis if left untreated  50% risk for stroke and death
 #1 most common presentation is related to thromboemboli, #2 mass effect
 management
- open surgical repair  carotid interposition graft with rGSV
- covered stent would be difficult due to size mismatch of
proximal carotid and distal to aneurysm
 CEREBROVASCULAR

Carotid body tumor

 neuroendocrine tumor
 supplied by perforators from external carotid
 work up
- 24 hour urine collection for metanephrines and catecholamines
- 123I-metaiodobenzylbuanidine scintigraphy (r CT, MRI) of chest and abdomen to exclude
other paragangliomas
- angiogram shows splaying of carotid bifurcation ("goblet sign")
 physical exam findings - Fontaine sign ?? - mass moves vertically with palpation
 Shamblin classification
- predicts ease of resection
- determined by preoperative imaging, operative findings, and pathologic analysis

Arteritis
 Takayasu arteritis
- younger patients, female predominance
- generally affects aorta (ie, middle aortic syndrome) and primary branches
 Giant cell arteritis
- older patients, equal M:F
- generally affects more distal arterial segments (ie, axillary artery is common)
 management
- endovascular or open intervention is not recommended during active inflammatory phase (ie, fever, myalgia,
rash, ESR)
- primary tx with immunosuppression (ie, steroids) to limit or prevent subsequent occlusive disease
» alternatives if resistant to steroids  azathioprine, MTX, MMF, cyclophosphamide; infliximab (anti-TNF alpha)
if resistant to everything
- open surgical reconstruction during quiescent or occlusive phase of disease if symptomatic
» most durable and appropriate revascularization in young patients is bypass graft from ascending aorta (which
is uninvolved in Takayasu)
- angioplasty has recurrent stenosis rate of 50% at mid-term follow up

VERTEBRAL / SUBCLAVIAN

Vertebral artery stenosis

 Horner syndrome is most common complication associated with open repair

Vertebrobasilar insufficiency
 severe carotid disease should be addressed first if present -- may improve vertebrobasilar perfusion via collaterals,
obviating the need for a more complex vertebrobasilar reconstruction

Positional posterior insufficiency (aka Bow hunter syndrome)

 caused by dynamic compromise of a dominant vertebral artery, typically secondary to compression of the vessel by a
hypertrophic osteophyte, cervical spondylosis, fibrous band, or thickened atlantoaxial membrane
 CEREBROVASCULAR
 digital subtraction angiography is preferred diagnostic tool because it identifies the precise
location and confirms rotational compression
 treatment options
- cervical fixation
- osseous decompression with removal of bone or fibrous tissue
- if pt has atherosclerotic disease  distal vertebral bypass is curative
- if pt has significant concurrent ICA disease and intact circle of Willis  tx carotid dz

Subclavian stenosis / steal syndrome

 proximal subclavian stenosis  retrograde flow through vertebral artery  arm supplied at
the expense of vertebrobasilar circulation
- reversed vertebral flow is a frequent incidental finding on carotid duplex
- does not need tx if asymptomatic
 more severe than typical vertebrobasilar insufficiency
 physical exam shows  BP in arm
 symptoms  arm weakness, vertebrobasilar insufficiency
 duplex shows reversal of flow through vertebral artery
 management
- if high-grade CAS and intact circle of Willis  CEA to allow  collateral flow to posterior
brain
- if no high-grade CAS  direct transposition of vertebral to carotid artery
» type of open revascularization for vertebral lesions depends on location
› ostial lesion or inflow stenosis  vertebral transposition or endarterectomy
› more distal V2 and V3 lesions  bypass with either the branches of ECA or ICA as inflow sources

Coronary-subclavian steal syndrome

 secondary to proximal subclavian artery occlusion
 tx  carotid-subclavian bypass with prosthetic graft
- short prosthetic grafts have better patency over vein in supraclavicular region
- subclavian to carotid transposition is not indicated in patient with LIMA coronary graft because of the ischemic
time during the anastomosis (carotid-subclavian bypass can be done distal to take-off of LIMA without disturbing
coronary flow)

.??  v-lab findings for subclavian stenosis vs. occlusion

 early systolic deceleration in vertebral artery  stenosis
 tardus parvus
- tardus = prolonged systolic acceleration - ie, slow upstroke
- parvus = small systolic amplitude and rounding of systolic peak
 reversal of flow in vertebral artery, significant difference in brachial BPs  occluded subclavian artery

Phrenic nerve injury

 can occur during exposure of left subclavian artery (ie, during carotid-subclavian bypass)
 left phrenic nerve courses over anterior scalene muscle, which lies between L subclavian vein (anterior) and artery
(posterior)
 results in elevated hemi-diaphragm and possible respiratory distress
CEREBROVASCULAR
 CEREBROVASCULAR

…….
AORTIC & ILIAC
 AORTIC & ILIAC
VESAP 

THORACIC AORTA

Blunt thoracic aortic injury (BTAI)

 SVS grade
- I - intimal tear
- II - intramural hematoma
» tx  urgent TEVAR within first 24 hours
- III - pseudoaneurysm
» most common
» tx  immediate TEVAR 
- IV - rupture
 CTA is best test for dx (Sn, Sp, convenient)
 TEVAR for BTAI
- ok to cover L subclavian  - most tolerate it without
adverse events (ie, arm ischemia)
- #1 complication is endograft malposition or endoleak

Type B aortic dissection

 management
- medical tx goal is to  BP and dP/dT to avoid rupture and stop dissection propagation
» start IV β blocker (ie, esmolol)
» goal SBP 100-120 and HR 60-80
- indications for repair (endovascular or open)
» aneurysmal degeneration (most common long-term complication)
» malperfusion (ie, ischemia of visceral vessels or iliac arteries)
» retrograde type A dissection
» rupture
» intractable pain
- long-term management - continue medical tx and surveillance if uncomplicated
» INSTEAD and ADSORB trials
› randomized pts with uncomplicated type B aortic dissection to best medical tx (BMT) vs. BMT and TEVAR
› both studies failed to show significant survival benefit with TEVAR
 complications
- aneurysm
» late aneurysm is most common complication in pts with uncomplicated type B treated medically (40%)
- retrograde type A dissection
» may have chest pain (extension into aortic arch) and/or neuro deficits (carotid)
» CTA of arch and thoracic aorta is diagnostic and helps with OR planning
 AORTIC & ILIAC
TEVAR zones

TEVAR zone 2 coverage

 defined by coverage of L subclavian but distal to L common carotid 
 subclavian revascularization is not mandatory but some reports show benefits including  risk of anterior/posterior
stroke, spinal cord ischemia, LUE ischemia
- patency rates of subclavian transposition and carotid-subclavian bypass are both excellent and equivalent

Penetrating aortic ulcer (PAU) / Intramural hematoma (IMH)

 PAU - characterized by disruption in aortic media, often occurs in pts with extensive atherosclerosis
 IMH - collection of thrombosed blood in media (ie, dissection w/o entry tear and w/ thrombosed false lumen)
 considerable overlap between the two, 80% of PAUs have associated IMH
 can occur anywhere along aorta
 differ from classic dissection bc they rarely propagate into branch vessels, they rupture more frequently, and more
common in older pts due to atherosclerosis association
 management
- EVAR - safe/effective, but need relatively long graft coverage to ensure exclusion of potentially diseased segments
- open - some surgeons prefer this due to concern for landing endograft in friable or dissected tissue

Spinal cord ischemia (SCI) after thoracic aortic surgery

 AORTIC & ILIAC
 mechanism of injury triad -  disruption of spinal cord's arterial collaterals,   spinal cord perfusion pressure, 
ischemia/reperfusion
- spinal cord perfusion pressure = arterial perfusion pressure - CSF pressure
- high aortic x-clamp  proximal HTN   CSF pressure   spinal cord perfusion
 can occur as late as 2 weeks post-op
 tx  lumbar drain ( CSF pressure) or permissive arterial HTN

ABDOMINAL AORTA

Thoracoabdominal aortic aneurysm

 Crawford classification (figures below)
 pre-op HD is the pre-op variable most associated with  mortality 
- age, emergent repair, male gender, extent II aneurysm also associated with  morbidity and mortality
 risk for paraplegia with open and endo repairs
- correlates with segmental arteries sacrificed
- pts undergoing repair for extent II aneurysm have highest risk
- adjunctive measures to  risk include lumbar drain, distal perfusion (using L heart bypass, cardiopulmonary
bypass, or circulatory arrest), spinal cord hypothermia, permissive HTN
- delayed paraplegia may be secondary to "second hit" phenomenon where vulnerable pt develops post-op
hypotension, lumbar drain malfunction, bleeding
» better prognosis than immediate, with 44% of pts recovering neuro function by discharge with the use of
adjunctive measures
- immediate paraplegia may be secondary to diffuse embolization to spinal cord

Abdominal aortic aneurysm

 risk factors
- smoking is strongest predictor (odds ratio 3-12)
-  vitamin B6 (odds ratio 3.75)
- family hx (odds ratio 1.9)
 protective factors
- diabetes - proposed mechanisms include hyperinsulinemia and hyperglycemia (can alter metabolism of arterial
matrix), and effects of pharmacologic tx in DM management (can stabilize mural thrombi and  inflammation)
- female gender - likely due to immune modulating effects of estrogen

Juxta-renal aortic aneurysm

 variable size and anatomy of renal arteries needs to be considered when assessing for possible fenestrated EVAR
- renal arteries < 5 mm have  risk for stenosis after covered stent placement
- snorkel configurations are even less optimal bc of long length of covered stent used
- unstented fenestrations are more likely to occlude because of dynamic movement of fenestrated main body,
renal arteries, and aorta
- early bifurcation of renal artery usually requires sacrifice of one of the branches by covered stent
 AORTIC & ILIAC
Aortocaval fistula
 arises as a result of contained aneurysm rupture into vena cava
 if open AAA repair, will see severe dark red bleeding from right posterior aspect of aorta into aneurysm sac
 tx  primary repair of bleeding hole from within aneurysm 
- do not attempt to mobilize vena cava or other structures
- if dx prior to open exploration, endo repair has been reported with superior results

EVAR vs. open repair

 open repair has 3-6x  risk of 30-day mortality compared to EVAR (EVAR-1, DREAM, OVER trials)
- early survival benefit persists for 2-3 years then survival rates become equivalent
 EVAR has  risk for late rupture (5.4% vs. 1.4% of open repairs) 

Renal transplant patients with AAA

 best tx is EVAR - hydrate, minimize contrast or use CO2, minimize ipsilateral catheter/wire manipulation 
 open repair - methods for renal protection
- keep warm ischemia time < 30 minutes (kidneys can tolerate ~ 50 min)
- temporary shunts/bypasses (aortoiliac, aortofemoral, subclavian, ax-fem)
- in situ perfusion with pump oxygenator via femoral vessels
- explant with temporary perfusion, then reimplant

Endoleak
 type 1
- 1a - proximal, 1b - distal
 type 2
- associated with hypogastric coil embolization and distal graft extension 
Graft infection
Endograft infection
 may present with general malaise, weight loss
 CT demonstrates air within aneurysm sac
 risk factors
- chronic infection in other anatomic sites, groin complications after EVAR, rupture
 treatment  complete graft excision with in situ or extra-anatomic reconstruction
- in situ reconstruction can use rifampin-soaked Dacron, vein, or cryo-preserved
aortic homograft
» in situ reconstruction is best for low virulence infections (ie, S. aureus or epi)
» extra-anatomic reconstruction better if gram negative, polymicrobial, grossly purulent, necrotic 
-  risk mortality than explants performed for endoleak
- aortic ligation usually avoided due to risk for stump blowout, major amputation, or reinfection of ax-fem graft 

Endograft limb occlusion

 most common in first 6 months after repair and more common with older generation grafts
 tx  endovascular recanalization successful if able to correct areas of kink or compression

Post-aneurysm repair colon ischemia

 management
- if hemodynamically stable and partial thickness (grade 1-2) on flex sig  observation, fluid resuscitation, abx
- if unstable or full thickness ischemia (grade 3) on flex sig  laparotomy and possible partial colon resection
- no role for anticoagulation

Abdominal compartment syndrome after ruptured AAA repair

  risk if ruptured, unstable pts with higher blood transfusion requirements; no change in risk for open vs. endo repair
  mortality
 AORTIC & ILIAC
 4 risk factors for compartment syndrome after EVAR for ruptured AAA
- use of aortic occlusion balloon
- massive transfusion
- coagulopathy
- need to convert to aorto-uniiliac device
 tx  immediate decompressive laparotomy (preferred over aggressive fluid resuscitation)

Acute aortic occlusion

 in situ thrombosis (ie, pre-existing aortoiliac atherosclerosis) is more common than a-fib (72% vs. 28%)
 tx depends on clinical scenario, no difference between open and endovascular revascularization

Aortic atherosclerosis
 can present with post-prandial abdominal pain (if visceral segment involved) and/or claudication
 tx  open aortic endarterectomy 
- endovascular management has risk for visceral or distal embolization, and dissection-associated occlusion of
visceral vessels

Middle aortic syndrome

 narrowing of abdominal or distal thoracic aorta  claudication, refractory HTN, post-prandial abdominal pain with
unintentional weight loss
- high rate of concomitant stenosis in renal (63%) and visceral (33%) arteries
 may be congenital or acquired (inflammatory causes, ie, Takayasu, temporal arteritis)
 most pts present in childhood or teen years
 tx  descending thoracic to distal aortic bypass with branches to celiac, SMA, and bilateral renal arteries

Trauma
 infrarenal aortic injury > 50% wall defect + associated colon injury with fecal contamination + hemodynamic instability
- tx  synthetic graft repair with omental coverage of graft and fecal diversion 
» aortic ligation is fastest option but will result in significant lower extremity hypoperfusion
» delayed, or even expedient extra-anatomic bypass after ligation will contribute to ischemia-reperfusion injury
» saphenous vein patch repair will take too much time and natural hx of this type of repair is not well known
» creation of neoaorta using femoral vein is a more robust conduit but takes too much time and expertise
» primary repair is not an option considering degree of defect

Abdominal exposures
 Cattell-Braasch maneuver (R medial visceral rotation)  IVC and origin of renal veins
 Mattox maneuver (left medial visceral rotation)  suprarenal aorta 

Blunt injury to common/external iliac artery (ie, MVC with pelvic frx)
 high morbidity and mortality
 pts with pseudoaneurysm, AVF, or major intimal tears with or without thrombosis  endovascular stent
 if unstable, open repair is not advised 
AORTIC & ILIAC
 AORTIC & ILIAC
RUTHERFORD 

CH 9 - TECHNIQUE: EVAR

Configurations
 bifurcated grafts used in 95% of cases
 can be unibody or modular
 aorto-uni-iliac (AUI) configuration
- can be used with contralateral iliac occlusion device and fem-fem bypass
- relative indications
» very small (< 15 mm) terminal aorta, which would not accommodate a bifurcated device
» severe unilateral iliac occlusive disease
» secondary tx of migration of a short-body endograft
 branched and fenestrated grafts can be used in juxtarenal and/or pararenal aneurysms and thoracic aneurysms where
there is inadequate normal aorta to achieve seal adjacent to a critical side branch

Sizing
 factors to consider as per intended use in IFU (instructions for use)
- iliac tortuosity
- vessel diameter (EI)
- angulation of distal neck
- aneurysmal sac orientation
- mural thrombus within aneurysm
- iliofemoral disease (ie, calcification, stenosis)
- iliac length (short iliac contralateral)
- iliac aneurysm (ipsilateral)
 neck diameter
- measure at level of lowest renal artery and 15 mm caudal
- grafts should be oversized 10-20% relative to aortic neck, usually about 3-4 mm
» EVAR devices range from 20-36 mm diameters, which txs aortic diameters of 18-32 mm
» TEVAR devices range from 21-45 mm and can tx 16-42 mm
- conical aortic neck
» > 2-3 mm change over the first 15 mm length of aortic length
» when oversizing, split the difference to give > 10% oversizing in large segment and < 30% in smaller segment
» if degree of size mismatch doesn't allow that, EVAR is not advised
 length
- count axial cuts from lowest renal artery to aortic bifurcation
» very accurate in absence of tortuosity or neck angulation
» axial measurements underestimate length between bifurcation and hypogastric arteries, esp if tortuous
» length measurements based on centerline calculations overestimate true length
- balleting iliac limbs can facilitate cannulation of contra gate of short-bodied modular grafts 
 iliac diameters
- oversize 10-20%

Patient selection
 character of aortic neck is the major anatomic factor predicting suitability for EVAR
- length, diameter, angulation, shape
- minimum neck length  10-15 mm
- angulation  < 45-60°
- maximum diameter  32 mm
 AORTIC & ILIAC
- shape
» parallel neck without any eccentric laminated thrombus is ideal
» irregular shaped necks have  risk of inadequate seal
› conical or reverse conical (see above)
› localized posterior bulge ("double bubble")
 RENAL & MESENTERIC
Look up tx for renal artery aneurysms based on location

Renal artery stenosis

 can be secondary to FMD, Takayasu arteritis, etc.
 predictors of improved renal function with revascularization
- rapid decline in pre-op renal function - most predictive
- high grade stenosis
- treating bilateral moderate to severe stenoses with stenting is more likely to be associated with improved renal
function (vs. treating higher grade unilateral stenosis)
- kidney length > 9 cm, renal resistive index (RI) < 0.8  renal function likely to improve with intervention
 most common complication of renal artery stenting is access site pseudoaneurysm

Renal artery aneurysm

 bilateral in 10% of cases
 most are saccular
 most commonly due to congenital medial degenerative process with weakness of elastic lamina
 most are asymptomatic, < 3% rupture
- calcification is thought to provide a protective factor against rupture
 indications for repair
- female currently or planning to become pregnant
- symptoms
- ≥ 2 cm if asymptomatic

Fibromuscular dysplasia
 aneurysms associated with FMD are usually only a few mm in size
 medial fibroplasia variant is most common
- angiographic appearance of “string of beads”
 catheter-based angiography is most accurate imaging technique
- able to visualize smaller branch vessels and identify the changes of aneurysm formation and dissection
- up to 25% of pts will have only branch lesions
 management  angioplasty alone
- stents are unnecessary and have  risk of restenosis
- known complication of angioplasty is dissection which would require a stent
- can treat bilaterally at the same time, no need to stage interventions

Renal arteriovenous malformation

 can be congenital (0.04% incidence, represents 20-25% of all renal AVFs) or acquired (spontaneous, FMD, aneurysm,
malignancy, trauma, percutaneous biopsy)
 most are asymptomatic
 tx when symptomatic  selective embolization is preferred
 RENAL & MESENTERIC
Acute renal vein thrombosis
 diagnosis  CT angiogram
 treatment
- correct fluid and electrolyte imbalances, HD if needed, antihypertensive meds, systemic anticoagulation
- percutaneous catheter-directed thrombectomy ± thrombolysis  rapid improvement in renal function and low
morbidity
- surgical thrombectomy is rarely used since parenchymal thrombus can't be cleared 
- all pts should undergo hypercoagulable work up

Nutcracker syndrome
 compression of distal segment of left renal vein between SMA and aorta
 symptoms include left flank pain radiating to buttock and hematuria

Segmental arterial mediolysis

 rare, acute, often self-limiting disorder generally limited to visceral vessels
 pathogenesis thought to be related to vasospasm
- overstimulation of alpha-1 receptors may lead to intense vasoconstriction followed by apoptosis or shearing
separation of the adventitia from the media, resulting in bleeding at the adventitial-medial junction
 classic findings include arterial dilation, aneurysms, hematomas, stenosis, occlusion

Hepatic artery aneurysm

 80% are extrahepatic
- common hepatic 63%
- right hepatic 28%
- left hepatic 5%
- right and left hepatic 4%

Splenic artery aneurysm

 most common visceral artery aneurysm
 female to male ratio 4:1
 rupture is rare when < 2 cm
 during pregnancy, rupture leads to 70% mortality for mother and 75% for fetus
- single most compelling indication for intervention is planned pregnancy
 treat with embolization, stent graft, or splenectomy when > 2 cm
 usually treat in transplant recipients

Pancreatic pseudoaneurysm of splenic artery

 differs from splenic artery due to atherosclerosis
 natural history is poorly defined with bleeding as potential consequence
 treat with covered stent

Pancreaticoduodenal artery aneurysm

 account for 10% of splanchnic aneurysms
 these and GDA aneurysms have higher propensity to rupture so usually tx'd regardless of symptoms
- tx women who are or are planning to get pregnant, transplant recipients, aneurysms > 20-25 mm
 can be tx'd endovascularly

SMA aneurysms
 uncommon, 5.5% of all splanchnic aneurysms
 most are proximal
 60% have reported infectious etiology (ie, mycotic aneurysm)
 tx if > 2 cm even if asymptomatic
- covered stent may not be appropriate depending on length and number of branches
 RENAL & MESENTERIC
- open repair associated with 10-15% mortality

Mesenteric collaterals
 meandering artery (aka arc of Riolan, artery of Moskowitz) (most prominent) connects SMA and IMA via middle
branch of middle colic artery and ascending branch of left colic artery
 pancreaticoduodenal arteries connect celiac axis and SMA
 marginal artery of Drummond connects SMA and IMA
 hypogastric collateral arises from hemorrhoidal artery

Acute mesenteric ischemia

 most common cause is an arterial embolic event
 2nd most common is acute arterial thrombosis superimposed on pre-existing severe atherosclerotic disease (25-30%)
 SMA is involved in 70% of cases
 least common cause is mesenteric vein thrombosis (6-9%)
 most common lab abnormality is leukocytosis (not lactic acidosis, this occurs with more advanced ischemia)
 CTA is preferred imaging modality
 treatment
- start systemic anticoagulation immediately
- exploratory laparotomy  overt necrotic bowel should be resected immediately to avoid further soilage
- open embolectomy for acute ischemia secondary to embolus
» expose SMA in root of mesentery, inferior to pancreas and transverse colon
» transverse arteriotomy preferred because it can be closed primarily
- mesenteric bypass if there is pre-existing mesenteric arterial occlusive disease
» choice of bypass conduit (synthetic vs. vein) is determined by degree of contamination
» can be antegrade or retrograde, tailor to circumstance

Chronic mesenteric ischemia

 duplex criteria
- celiac  PSV > 200 (70% stenosis) or EDV > 55 (50% stenosis)
- SMA  PSV > 275 (70% stenosis) or EDV > 45 (50% stenosis)

SMA Doppler waveforms

 normal, fasting pt  high resistance, PSV < 275, no spectral broadening
 normal, postprandial  low resistance, slightly increased PSV, little to no spectral broadening
 SMA stenosis (> 70%), fasting  delay in systolic upstroke, markedly elevated PSV, significant spectral broadening (see
picture)
 RENAL & MESENTERIC

Non-occlusive mesenteric ischemia (NOMI)

 occurs when limited blood flow to gut results in insufficient O2 delivery for given demand despite patent vessels
- inciting factors include MI, septic shock, prolonged vasopressors, excessive fluid removal with HD
 angiogram shows spasm of mesenteric arcades and alternating dilation and narrowing
 tx by alleviating source of hypoperfusion
- in rare cases, intra-arterial infusion of vasodilator (ie, nitro, papaverine) into SMA may be considered

Median arcuate ligament syndrome

 tx with laparoscopic decompression of celiac axis

SMA syndrome
 characterized by compression of 3rd portion of duodenum by SMA  intermittent/partial SBO
 can be secondary to loss of mesenteric fat from rapid weight loss or catabolic states
 aorto-mesenteric angle < 25° can be associated with duodenal compression (normal 45°)
 management
- trial of conservative tx with NJ feeds to restore nutritional status and potentially relieve symptoms
- if fails  then duodenojejunostomy can bypass obstruction
- no role for vascular reconstruction

Mesenteric bypass
 antegrade bypass from supraceliac aorta is preferred because of  long-term patency and straightforward geometry
 retrograde bypass
- indicated when antegrade bypass or aortomesenteric endarterectomy are not feasible
 RENAL & MESENTERIC
» severe cardiac disease (increases risk of clamping supraceliac aorta)
» inaccessible supraceliac aorta due to previous operations
» severely calcified or aneurysmal supraceliac aorta
- prosthetic graft preferred in absence of infected field due to  risk of kinking compared to vein

Exposures
 SMA
- in root of mesentery, inferior to pancreas and transverse colon
 infrarenal IVC
- Cattell-Braasch maneuver  medial rotation of R colon, hepatic flexure, duodenum
UPPER EXTREMITIY
 UPPER EXTREMITIY
Subclavian artery stenosis
 common but usually asymptomatic
 present with > 20 mmHg difference between brachial pressures
 sx include exertional arm pain, fatigue, numbness; may have atheroembolic digital ischemia ± tissue loss
 tx if symptomatic  angioplasty with balloon expandable stent placement if preferred
- usually need to tx regardless of sx if pt has ipsilateral AVF or LIMA-CABG

Subclavian steal syndrome

 proximal subclavian stenosis  retrograde vertebral flow  arm supplied at the expense of
vertebrobasilar circulation
 more severe than typical vertebrobasilar insufficiency
 symptoms  arm weakness, vertebrobasilar insufficiency
 duplex shows reversal of flow through vertebral artery
- also a frequent incidental finding on carotid duplex and does not need tx if asx
 management
- if high-grade CAS and intact circle of Willis  CEA to allow  collateral flow to posterior
brain
- if no high-grade CAS  direct transposition of vertebral to carotid artery
» type of open revascularization for vertebral lesions depends on location
› ostial lesion or inflow stenosis  vertebral transposition or endarterectomy
› more distal V2 and V3 lesions  bypass with either the branches of ECA or ICA as inflow sources

Coronary-subclavian steal syndrome

 secondary to proximal subclavian stenosis/occlusion proximal to an internal mammary to coronary bypass
 tx  carotid-subclavian bypass with prosthetic graft
- can be done distal to take-off of LIMA without disturbing coronary flow
- short prosthetic grafts have better patency over vein in supraclavicular region
- subclavian-carotid transposition is not indicated in pt with LIMA coronary graft because of ischemic time
- subclavian-subclavian bypass has inferior patency rate

Subclavian artery atherosclerosis

 atherosclerotic plaque of supra-aortic trunks most commonly affects L subclavian artery at its origin

Dysphagia lusoria / aberrant R subclavian artery

 esophageal compression secondary to aberrant R subclavian artery (travels posterior to esophagus)  dysphagia
 most common congenital anomaly of aortic arch (0.5-1% prevalence)
 associated with non-recurrent R laryngeal nerve
 aberrant R SC has 60%  risk for aneurysmal degeneration in proximal portion (Kommerell diverticulum)
 tx  transposition of R SC onto R common carotid ± thoracic aortic endograft to cover origin of aberrant R SC

Iatrogenic subclavian artery injury (ie, inadvertent line insertion)

 location makes manual compression difficult
 best tx  covered stent
 open surgery sometimes needed
- proximal subclavian  median sternotomy
- distal subclavian  infraclavicular incision

Subclavian artery aneurysm

 in teens, young adults - usually result from post-stenotic dilation secondary to cervical rib
 management
- arterial decompression (ie, cervical rib resection) via supraclavicular approach allows for complete assessment of
subclavian artery and exposure of brachial plexus which is often displaced anteriorly
 UPPER EXTREMITIY
- laterality of dominant vertebral artery is the most important anatomic consideration regarding neurologic
morbidity 

Left subclavian-to-carotid transposition

 transverse supraclavicular incision over the two heads of SCM
 thoracic duct and L vertebral vein are ligated
 omohyoid muscle is divided to improve exposure of proximal subclavian artery and origin of vertebral artery
 anterior scalene is not usually divided 
 L SC artery ligated proximal to L vertebral artery, then anastomosed to L common carotid posterior to jugular vein

Thoracic outlet - three anatomic components

 scalene triangle
- most common site of brachial plexus compression
- site of cervical or anomalous first rib if present, compressing brachial plexus
 costoclavicular space - between first rib and clavicle
- traversed by all 3 structures (subclavian artery, vein, brachial plexus)
- most common site of subclavian vein compression
 pectoralis minor space

Arterial thoracic outlet syndrome (TOS)

 rarest form of TOS
 most commonly from compression of subclavian artery at level of first rib within scalene triangle
- can present with subclavian aneurysm
- tx  decompression with at least first/cervical rib resection ± scalenectomy
» supra- or infraclavicular incision if you need to reconstruct artery (vs. transaxillary if just resecting rib, ie, for
vTOS)
 variant (20%) - positional compression of axillary artery by head of humerus during overhand throwing
- tx  axillary artery reconstruction (including interposition bypass, patch angioplasty, and/or thrombectomy) with
ligation of aneurysmal branch vessels
 UPPER EXTREMITIY

Venous thoracic outlet syndrome (aka Paget Schroetter syndrome)

 usually young athletic person presenting with upper extremity swelling, thrombosis
 management  pharmaco-mechanical thrombolysis/thrombectomy then early first rib resection
- first rib resection and division of subclavius tendon is necessary for definitive decompression and should not be
delayed more than several weeks to prevent recurrence
- pharmaco-mechanical thrombolysis can improve symptoms between time of presentation and surgical
reconstruction
- subclavian vein stents have high incidence of thrombosis, fracture, deformation and should be avoided

Neurogenic thoracic outlet syndrome

 most common form of TOS (95%)
 most common site of compression is at scalene triangle
- area where brachial plexus's 5 roots (C5-T1) become 3 trunks

Thoracic outlet decompression

 transaxillary approach
- better visualization for rib resection
- not suitable for cases that require vascular reconstruction
- may be more challenging in context of cervical rib because brachial plexus is usually displaced anteriorly
 supraclavicular approach
- allows for identification of the cause of compression, resection of first and cervical ribs, and vascular
reconstruction (ie, can get proximal control)

Axillary artery hematoma

 artery runs with brachial plexus in axillary sheath and bleeding (ie, from access site) can result in hematoma tracking
down sheath
 hematoma may be unimpressive on physical exam and pulses likely intact
 first finding is usually sensory deficit or paresthesias that can rapidly progress to motor loss
 diagnostic tests will likely delay treatment
 tx  urgent surgical decompression

Quadrilateral space syndrome

 chronic arterial compression with overhand motion in athletes (pitchers, volleyball players)
 posterior humeral circumflex artery and axillary nerve run through quadrilateral space -- teres minor (superior),
humeral shaft (lateral), teres major (inferior), long head of triceps (medial)
 can lead to aneurysm or occlusion

Brachial sheath hematoma (ie, trauma/GSW)

 neurologic sx may be secondary to ischemia or nerve compression
 even small, non-palpable brachial sheath hematomas may cause significant neurologic complications and may be
difficult to detect with imaging
 management
- exploration with interposition vein graft
- covered stent placement may be suboptimal option depending on length of defect, location in brachial artery
(which is dynamic during arm motion, relatively small in diameter, prone to spasm), and inability to perform
simultaneous hematoma evacuation
- consider fasciotomy for extensive injuries, crush injuries, or severe/prolonged ischemia

Radial artery access complications

 Allen test performed prior to determine risk of digital ischemia if occlusion occurs
 thrombosis (occurs in 5-10%)
-  risk with  sheath size
 UPPER EXTREMITIY
- tx  short-term anticoagulation (ie, 4 weeks)
 stenosis (occurs in 25%)
- most resolve with time

Hypothenar hammer syndrome / ulnar artery aneurysm

 repeated blunt trauma to hypothenar part of hand  superficial branch of ulnar artery compressed against hamate 
may develop ulnar aneurysm, usually distal to pisiform bone at wrist
 angiogram shows artery with corkscrew appearance due to intraluminal thrombus
 management
- repair with reversed vein graft (branch of GSV or foot vein give reasonable size match)
- thrombolysis first if there is significant digital ischemia from aneurysm thrombosis or embolization

Thromboangiitis obliterans (Buerger disease)

 chronic, non-atherosclerotic arteritis characterized by relapsing episodes of distal extremity ischemia
 classically presents as digital gangrene in young male smoker
 almost always affects more than 1 extremity, otherwise consider other diagnoses
 imaging shows thrombosis of small and medium-sized arteries (often distal to brachial and popliteal arteries) with
corkscrew-shaped collaterals secondary to hypertrophied vasa vasorum
 management
- smoking cessation is most important intervention for preventing progression, ulceration, gangrene
- iloprost (prostacyclin) may improve symptoms

Raynaud phenomenon
 prevalence of 3-5% in general population
 triphasic change in skin color - need at least biphasic change for diagnosis
- ischemia (white)  cyanosis (blue)  reperfusion (red)
 associated diagnoses may be rheumatologic (scleroderma, SLE), hematologic (cryoglobulins, paraneoplastic disorder),
neurologic (carpal tunnel), drug-related (ergotamine)
 management
- avoid cold, smoking, aggravating medications (ie, caffeine)
- first line drug tx  antiplatelet and low-dose DHP CCBs (ie, nifedipine, amlodipine, felodipine)
- alternatives  PDE inhibitors (ie, sildenafil), topical nitrates, ARBs, SSRIs
- avoid βB
 look up types of Raynaud and waveforms

Central stenosis / non-malignant SVC obstruction

 pt with hx of multiple dialysis catheters presents with facial swelling, HA, dizziness when bending over
 endovascular tx is effective over short-term and does not adversely affect future open options
 open reconstruction in pts not suitable for or who fail endovascular tx
- straight spiral saphenous vein graft is best conduit

Left innominate vein ligation

 occasionally performed for aortic arch exposure or part of mediastinal resection for large tumors
 venous drainage develops collaterals from hemi/azygous, internal mammary, lateral thoracic, superficial
thoracoabdominal, vertebral plexus, transverse sinus veins
 may develop painless arm swelling  most pts can be tx'd conservatively (ie, compression)

Internal mammary artery ligation

 UPPER EXTREMITIY
 usually ok unless it's needed as inflow for coronary bypass or myocutaneous muscle flap

Thrombolysis for acute DVT

 absolute contraindications
– active bleeding
– recent head injury (2 weeks)
– recent spinal surgery ( 3 weeks)
– thrombocytopenia (< 100)
 relative contraindication
- pregnancy 

EXPOSURES

proximal L common carotid and proximal L subclavian

 anterior thoracotomy with partial superior median sternotomy and left supraclavicular incision (ie, trapdoor)

proximal L subclavian
 supraclavicular incision

proximal axillary artery

 infraclavicular incision

balloon vs. self expanding stents

 balloon expanding stents have more radial force and are easier to place precisely (use for any orificial lesions)
 self expanding are more malleable, can be better for longer and more tortuous lesions (ie, SFA)
 LOWER EXTREMITIY
QUESTIONS  44

Acute limb ischemia

 anticoagulation
- unfractionated heparin - initial bolus (100 units/kg ) then continuous gtt (18 units/kg/hr)
- leads to thrombus stabilization, prevents propagation, has vasodilatory effect

Rutherford classification of acute limb ischemia

SVS lower extremity threatened limb classification system ("WIfI")

 considers clinical factors of wound, ischemia, foot infection

Acute traumatic limb ischemia

 unstable pt with GSW to thigh  SFA thrombectomy and shunting
- bypass with contralateral saphenous vein may be optimal but not in unstable patient
- need damage control  shunting associated with low thrombosis rate (5%) and amputation rate < 20% 
 vascular shunts
- most effective in proximal extremity injuries (ie, femoral, popliteal vessels)
- most common complications are thrombosis and distal embolization 

Claudication
 ABI < 0.9 suggests arterial occlusive disease 
 differential diagnosis in young patients
- thromboangiitis obliterans
- adventitial cystic disease - classically associated with loss of distal pluses after knee flexion (Ishikawa sign)
- popliteal artery entrapment
- chronic exertional compartment syndrome
- lower extremity trauma
- infectious embolism
- fibromuscular dysplasia
- vasculitis
- middle aortic syndrome
- persistent sciatic artery

External iliac artery endofibrosis

 seen in high performance cyclists and other athletes
 extreme hip flexion  repetitive trauma to EIA secondary to iliopsoas muscle or inguinal ligament in setting of high
blood flow, as well as mechanical stress from bend on artery
 tx  inguinal ligament release and EIA patch angioplasty or interposition graft 

Post-catheterization pseudoaneurysm
 risk factors include larger sheaths size, punctures either proximal or distal to CFA, females, anticoagulation
 management
 LOWER EXTREMITIY
- asymptomatic and < 2 cm  conservative management
- symptomatic and/or > 2 cm  US-guided manual compression or thrombin injection
- open repair if there is overlying skin changes or unfavorable neck (ie, short, wide neck)

Infected femoral pseudoaneurysm in drug abuser

 tx  complete excision and debridement 
- in situ reconstruction carries a high risk of blowout or reinfection

Persistent sciatic artery (PSA)

 congenital vascular anomaly resulting in atresia of SFA
- "complete" type (figure)  PSA continues into popliteal artery, serves as principle blood supply to lower
extremity, and associated with hypoplastic CFA and SFA which ends at adductor canal
- "incomplete" type  PSA is hypoplastic and is a continuation of hypogastric, courses
through sciatic foramen into thigh, SFA remains principal supply to lower extremity
PSA
 prone to atherosclerosis, aneurysmal degeneration, thromboembolism, sciatic
neuropathy from nerve compression
 pulsatile buttock mass on physical exam

Popliteal artery aneurysm

 main risk is thrombosis and limb loss, although rupture is also possible
 should be repaired, even when small, if the lumen has a thrombus burden of > 50%
 tx  open or endo repair are both reasonable
- endovascular repair has shown lower complication rates and shorter hospital stay 
» tibial runoff is the most important determinant of stent graft patency 
» seal neck of 15 mm is adequate
» vessel calcification and geniculate branches are not a contraindication

Popliteal entrapment
 more common in younger, active patients

Blunt popliteal artery injury

 posterior knee dislocation  blunt shear force of vessel  dissection and disruption of intima and media
 treatment
 LOWER EXTREMITIY
- if pulse discrepancy  angiography and repair
- normal pulses  serial pulse exam and external fixation

Tibial aneurysm
 may be secondary to vascular type Elher-Danlos
 pt should undergo cardiac evaluation due to  risk for coronary disease at younger age 

Diabetic foot ulcers

 pathophysiological mechanisms are primarily neuropathic 
- sensory neuropathy of type A myelinated α-fibers  loss of proprioception protection
- autonomic neuropathy (or sympathetic dysfunction)  shunting of blood from skin and loss of oil and sweat gland
function  dry skin  risk for cracks and fissures
 management
- IV antibiotics and debridement if acutely infected
- revascularization to wound angiosome may be beneficial for limb-related outcomes
» ie, if ulcer at first metatarsal  bypass to PT (medial plantar branch of PT supplies dorsum of 1st metatarsal) 

Cholesterol embolization (aka Blue toe) syndrome

 diffuse microscopic arteriolar occlusion by showers of cholesterol emboli induced by endovascular manipulation
- most likely from aortic source
- can see cholesterol crystals on biopsy
 present painful blue toes ± new onset renal failure
 best imaging test is CTA C/A/P

Compartment syndrome
 compartments
- anterior  …
- lateral  superficial peroneal nerve
- superficial posterior  soleus muscle
- deep posterior  tibial nerve , PT artery, flexor hallicus longus
 decision to perform fasciotomies based on clinical criteria (ie, tense compartments with motor or nerve dysfunction)
 additional indications
- prolonged ischemia > 6 hours - most commonly accepted indication
- pts who cannot be reliably examined following reperfusion (ie, intubated sedated pt)
- combined arterial and venous injuries necessitating operative repair
- reperfusion associated with arterial reconstruction
- concomitant crush injuries or significant fractures
 compartment pressures
- dynamic compartment pressures = mean difference between arterial pressure and intracompartmental pressure
- fasciotomy warranted if difference between intracompartmental pressure and MAP is < 40 mmHg

Gluteal compartment syndrome

 gluteal region has 3 compartments that require assessment
- gluteus maximus - includes inferior gluteal artery and nerve 
- medius/minimus - includes superior gluteal artery and nerve
- tensor fascia lata
 normal compartment pressures are 13-14 mmHg, consider decompression if > 30
 tx  decompression via prone position through expansile-type Kocher-Langenbeck incision

Pathology
 intimal fibroplasia type of FMD  intimal collagen deposition and disruption of internal elastic lamina
 adventitial cystic disease  mucin-containing cystic structures
 LOWER EXTREMITIY
- can affect pop, iliac, radial, ulnar arteries and peripheral veins
 medial calcific sclerosis  dystrophic calcification
- seen in pts with DM and renal failure
 Ehler-Danlos syndrome  disorganized collagen fibers and rare collagen bundles

Bypass conduits
 autogenous vein
 prosthetic (ie, polytetrafluoroethylene)
- same intermediate (ie, 2 yr) patency rate as autogenous saphenous vein when used for above knee bypasses
- patency  significantly when sewn to below knee targets
 cryopreserved vein
- worse patency compared to autogenous vein

Catheter-directed thrombolysis
 can be used to treat emboli but may need longer infusion times and use of adjunctive mechanical thrombectomy
 absolute contraindications
- recent hemorrhage (ie, GI bleed)

Endovascular stents
 covered stents
- allow for immediate restoration of arterial flow in clinical scenarios where thrombolysis may be contraindicated
(ie, recent surgery or hemorrhage)
 bare metal stents
- not used for acute and subacute thrombus due to risk for "cheese-grating" with subsequent distal embolization
 self-expanding
- more malleable, can be better for longer and more tortuous lesions (ie, SFA)
- use in areas of repetitive motion (ie, distal external iliac)
 balloon expanding
- have more radial force and are easier to place precisely (use for any orificial lesions)

Endovascular balloons
 plain balloon
 drug-coated
- coated with an excipient and paclitaxel
» excipient - aids in transfer of drug from balloon to arterial wall
» paclitaxel
› diffuses through intima to media and adventitia
› has antiproliferative effect on smooth muscle cells  primary mechanism for preventing restenosis
- RCTs show superior 1° patency compared to plain balloons when treating SFA lesions

Atherectomy
 RCTs show  rate of bailout stenting for residual stenosis or dissection compared to PTA with selective stenting
 DIALYSIS ACCESS
End stage renal disease
 treatment options - AV fistula, PTFE graft, venous catheter, PD catheter, transplant

General considerations
 adequate flow rates
 minimal complications
 long-term patency
 acceptable cosmesis

Pre-op considerations
 eval site for patency and signs of infection
 restrict arm -- no BP or PIVs

Access types
 AV fistula
– better 1° and 2° patency than graft
– criticisms of fistula first
-  number of non-maturation
-  number of remedial procedures (thus  cost)
-  catheter-dependence time
– maturation (vein arterialization and increase in flow) - median 98 days
 AV graft
– large surface area, easy cannulation, preferred by HD techs
–  complications
–  "maturation" time
– amendable to remediation tx if thrombosis or failure
– unlimited supply

Operative management

Post-operative care and follow up

 DIALYSIS ACCESS
VESAP 
Anatomy
 cephalic + median cubital + basilic vv.  H
– cephalic vein (lateral forearm) communicates with median cubital vein in antecubital fossa
– median cubital vein drains into basilic vein (medial forearm/arm)

General considerations
 patency
– autogenous > prosthetic
– larger inflow artery > smaller
– larger outflow vein > smaller
 overall cost per patient-yr at risk
– tunneled catheter < AVF < AVG
 access as far distally on non-dominant arm if possible

Pre-op evaluation
 vein mapping
– prospective RCT showed  initial failure rate but no difference in 1° patency at 1 yr 
– not needed if pt has adequate visible superficial veins and no signs of central venous stenosis
 UE segmental pressures and pulse volume recordings (PVRs) - if any abnormality on pulse exam
 arteriography
– allows for identification and possible intervention on arterial inflow stenosis
– in pre-HD pts, risk of contrast may be prohibitive (use segmental pressures and PVRs instead)

AV fistula
 requires outflow vein ≥ 3 mm
 benefits of regional anesthesia (ie, brachial plexus block)
–  vasodilation of artery and vein   flow in fistula
- lasts up to 8 weeks post-op
- allows for use of more distal vein
- shown to  1° patency and function at 3 months
– improvement in reported pain control - motor and sensory blockade lasts 6-12 hours
 maturation criteria - rule of 6s
– flow rate 600 cc/min
– vein diameter 6 mm
– access depth 6 mm below skin
 maturation failure
– inflow artery < 2 mm consistently shown to be associated with failure 
– diabetes and female gender associated with  failure rates of wrist AVFs
– basilic transposition in obese pts have  failure rate
 access techniques …
– buttonhole …  hematoma,  bacteremia/abscess
– rope-ladder …

AV graft
 requires outflow vein ≥ 4 mm but does not need to be anatomically accessible
 early cannulation grafts (Acuseal, Flixene, Vectra)
- allow for expedited access and  time of catheter dependence
- sealing properties of layered graft minimize bleeding at suture line and cannulation holes
- most can be used within 24 hours
- important in pts who are immunosuppressed and have had previous line infections
- may have  risk for ischemic steal (Accuseal specifically)
- similar long-term patency as PTFE
 DIALYSIS ACCESS
 surveillance
- routine duplex every 3-4 months   detection of graft stenosis but also  invasive interventions with
indeterminate impact on patency

Complications
 access dysfunction
– clinical features include absent thrill, discontinuous bruit, edema distal to access, difficult cannulation,
inability to reach target flow, prolonged bleeding, discordance between delivered and prescribed HD dose
(Kt/V)
– other measures of surveillance
- static venous pressures (measured in HD machine)
- access flow measurements
 flow measurements performed with US dilution which determine access blood flow after
injecting saline through reversed-line HD circuit
 rate < 600 cc/min or > 25% below baseline suggest venous stenosis
 early access failure (within 30 days of surgery)
– in absence of technical failure (ie, twisted or stenotic anastomosis), most commonly due to inadequate
venous outflow, which may be secondary to inadequate vein caliber or central venous stenosis
– less common causes included poor arterial inflow, anastomotic stenosis, or hypercoagulable state
 early thrombosis
– associated with female gender, forearm AVF, small arterial size, outflow vein 2-3 mm, protamine use
– diabetes and non-compliant arteries have lower frequency of early thrombosis
– short-term antiplatelet use in peri-op period associated with  rates of early thrombosis
 late thrombosis
– most commonly due to intimal hyperplasia of venous outflow tract
– second most common cause is central venous stenosis
 arterial steal  hand ischemia
– strategies to  risk
- use axillary artery inflow in high-risk pts 
- create radiocephalic fistula when feasible
- proximal radial artery instead of brachial for inflow when possible
- limit size of anastomosis if brachial inflow is necessary
- tapered grafts to limit inflow have mixed results
– best test for dx  digital plethysmography with and without fistula compression 
– management
- evaluate with arteriogram to identify any proximal arterial stenosis
- severe, immediate  immediate ligation of AVF
- less severe  various techniques to relieve steal symptoms
 banding of fistula outflow tract (to  resistance in fistula)
 proximalization of arterial inflow (PAI)
 revision using distal inflow (RUDI)
 distal revascularization and interval ligation (DRIL)
- ligation of the arterial outflow tract just distal to arterial anastomosis followed by
bypass from artery proximal to anastomosis to artery distal to area of ligation
- effective in treating ischemic pain and tissue loss but less effective for neurologic
deficits that have already occurred
 high output heart failure
– occurs when  R-side circulatory volume reduces overall L-side volume   HR and stroke volume to
compensate   cardiac output  ventricular hypertrophy and eventually heart failure
– risk factors include underlying cardiac dz, anemia, upper arm AVF (vs. forearm), males, and upper arm fistula
in same arm a previously functioning forearm fistula
– TTE usually shows LV dilation and pHTN
– management
 DIALYSIS ACCESS
- fistula banding - constricts inflow and  access volume
 banding inflow artery is not recommended 
- surgical ligation may be needed if no response to banding
- re-siting AV anastomosis to smaller, distal artery
 inotropes (ie, digoxin) are not effective
 pseudoaneurysm
– defects in vessel wall due to trauma of repeated punctures (AVG > AVF)
– commonly occurs in pairs due to arterial and venous punctures with each session
– dx is clinical but can be confirmed with duplex ("yin-yang sign" on color-flow is created by turbulent flow)
– intervention indicated if growing or ulcerated
- open tx  bypass around involved portion and replace with either transposed vein or prosthetic
- excision of aneurysmal areas is rarely required
- can continue HD by accessing uninvolved part
- can use endovascular covered stent grafts but may  incidence of future complications at access site
 ischemic monomelic neuropathy 
– rare complication that requires prompt dx to avoid permanent neurologic injury
– almost exclusively in diabetics, immediately after creation of a brachiocephalic or antecubital AVF/AVG
– characterized by acute pain and weakness in forearm and hand muscles, wrist drop, often with sensory loss
– underlying cause is sudden diversion of blood supply to nerves of forearm and hand with resulting injury to
nerve fibers
– untx'd pts develop claw-hand deformity with loss of function and severe neuropathic pain
– tx  immediate ligation of AVF
 seroma (AVG)
– sterile, ultrafiltered serum surrounded by fibrous pseudocapsule
– affects 2-4% of pts with AVG
– caused by failure of synthetic graft to become encapsulated
– may lead to infection, skin necrosis, graft thrombosis, loss of graft puncture area
– tx  removal of seroma and replacement of the involved portion of graft
- continued serial aspiration and closed suction drainage are assoc'd with  risk for infection

Central venous stenosis

 commonly in subclavian vein in pt with hx of prior catheters
 secondary to intimal hyperplasia
 can be asymptomatic with only  dialysis venous pressures, or symptomatic with  bleeding at puncture site,
extremity edema, varicosities, pigmentation, venous ulceration
 management
– angioplasty can be successful but with limited durability
– bare metal or covered stents have not been proven to  durability but can used if angioplasty alone is
suboptimal or if there is recurrent stenosis
– open methods (ie, subclavian to IJ bypass, jugular turndown) used when endovascular tx fails
– ligation of access only as a last resort

HeRO graft
 used in pts with central venous stenosis/occlusion (provided it can be crossed endovascularly)
 proximal anastomosis to an artery or existing HD access, device placed in R atrium for direct outflow
- allows for bypass of venous occlusion while maintaining access without bridging with tunneled catheter
 lower infection rate compared to tunneled catheter
 contraindications
- EF < 20%
- SBP < 100
- brachial a. < 3 mm
- active infection
 DIALYSIS ACCESS
Short-term catheters
 double lumen non-cuffed catheters that can be placed at bedside
 right IJ is preferred with catheter tip at SVC just above RA (best flow rates)
– subclavian has risk for stenosis
– femoral has risk for infection
 DIALYSIS ACCESS
RUTHERFORD 
General considerations

Dialysis catheters

Complex access

Failing and thrombosed access

Nonthrombotic complications
 VENOUS & LYMPHATIC
Pictures
 VENOUS & LYMPHATIC
VESAP 

Questions  37, 42 & 43 re: AVF creation for long-term patency

Anatomy
 superficial venous system
- greater saphenous vein (GSV) ***
- GSV exits fascia in proximal thigh  becomes superficial accessory GSV (aka vena saphena magna accessoria
superficialis) 
 sural nerve  lateral ankle, foot, heel sensation
» adjacent to small saphenous vein (SSV) (see US image below) 

SSV and sural nerve

Pulmonary embolus
 massive PE with hemodynamic instability and R heart failure  systemic thrombolysis  over catheter directed lysis

Retroperitoneal sarcoma
 most common caval tumors
 often require en bloc resection of IVC
- < 50%  patch angioplasty repair with autogenous vein or bovine pericardium
- > 50%  ringed PTFE favored to provide radial force that resists visceral compression, 90% 5 yr patency 

Cattell-Braasch maneuver
 medial rotation of R colon, hepatic flexure, duodenum  exposes infrarenal IVC

Chronic IVC occlusion

 ranges from asymptomatic to severe BLE edema, hyperpigmentation, ulcers
 tx  endovascular recanalization with iliofemoral stenting
- compression alone does not tx underlying cause
- angioplasty alone is not durable
- open reconstruction with femorocaval bypass is morbid
 VENOUS & LYMPHATIC
Nutcracker syndrome
 compression of L renal vein as it passes between SMA and aorta
 presents with abdominal pain, pelvic congestion, hematuria, proteinuria, orthostatic intolerance
 L renal vein tributaries include L gonadal v, L ureteral v, capsular vv, lumbar vv, suprarenal v, inferior phrenic v

Pelvic congestion syndrome (PCS)

 chronic pelvic pain, dyspareunia, urinary urgency, painful LE varicose veins (non-saphenous vein reflux)
 transabdominal ultrasound is most complete initial imaging work up 
- can confirm pelvic varicosities, measure parauterine and ovarian vein diameters and reflux, eval for left renal and
iliac vein compression, and rule out ovarian, pelvic, iliac vein reflux
- transvaginal ultrasound is good for pelvic pathology but doesn't eval L renal vein compression or ovarian v reflux
- CT venogram doesn't allow for real time assessment of ovarian vein reflux

May Thurner syndrome

 compression of L CIV between R CIA and L5 body  chronic venous insufficiency of LLE
 venous duplex shows turbulence (mosaic appearance), abnormal Doppler signal, continuous flow with valsalva,
sluggish flow with no spontaneous variation, poor augmentation, absent respiratory variation
- most Sn duplex criterion for stenosis > 50% is a post-stenotic to pre-stenotic peak vein velocity ratio of 2.5
 tx  stent

Iliofemoral DVT
 management
- controversial
» ATTRACT trial showed no significant difference in rate of post-thrombotic syndrome with catheter-directed
thrombolysis vs. anticoagulation alone
» CaVenT trial showed significant  rate of post-thrombotic syndrome after catheter-directed thrombolysis
» CHEST guidelines (grade 2C)  anticoagulation alone
- patency after open surgical thrombectomy is improved by AV fistula creation 

Common femoral vein transection

 repair with lateral venorrhaphy, has better patency than bypass or interposition graft
 venous ligation if pt is unstable, but has high incidence of PE
 creation of AVF does NOT  long-term patency in this situation

Acute DVT
 management
- mechanical prophylaxis   serum levels of tPA
- CHEST guidelines  anticoagulation alone (over catheter directed thrombolysis) using LMWH over NOACs or vit K
antagonists 
 VENOUS & LYMPHATIC
- pts with cancer and active malignancy  LMWH for first 3 months (ie, dalteparin , enoxaparin)
- catheter directed thrombolysis   risk and severity of post-thrombotic syndrome compared to anticoagulation
alone 
 risk of recurrence highest in pts with active malignancy
- provoked DVT  1% at 1 yr, 3% at 5 yrs
- non-surgical provocation  5% at 1 yr, 15% at 3 yrs
- unprovoked DVT  10% at 1 yr
- active malignancy  15% at 1 yr

Distal (calf) DVT

 CHEST guidelines suggest treating with anticoagulation, unless high risk for bleeding then follow up with US in 2 w 

Varicose veins
 most common manifestation of primary chronic venous insufficiency 

Venous ulcers
 most important aspect of tx is compression
 superficial system should be tx'd in pts with pathologic GSV reflux

CEAP classification
 VENOUS & LYMPHATIC

Venous insufficiency treatment

 thermal ablation (ie, laser, RFA) is preferred
 foam, glue, and mechanical-chemical txs can also be used
 ligation and stripping can be done but more invasive
 perforator ablation only if pathologic, ie > 3.5 mm

Endovenous radiofrequency ablation (RFA)

 RFA energy causes ablation of endothelium  thrombus formation  collagen contraction  vein contraction
 no absolute contraindications; relative contraindications include:
- active superficial venous thrombosis is main contraindication
- superficial vein in close proximity to skin  may cause burning
- GSV < 2 mm (risk of perforation) or > 15 mm (lower efficacy) 
 most common recurrence pattern is anterior accessory saphenous vein (AASV) incompetence 

Cyanoacrylate embolization (CAE)

 non-inferior to RFA
  ecchymosis compared to RFA 
 VENOUS & LYMPHATIC

Endovenous heat-induced thrombus (EHIT)

 can occur after RFA or endovenous laser ablation (ELA) of GSV
 risk factors
- large diameter GSV, age,  D-dimer at time of tx
 classification based on extent of thrombus into deep venous system and risk of propagation
- level 1  closure with thrombus below level of epigastric vein (normal finding after thermal ablation)
- level 2  closure with thrombus extension flush with orifice of epigastric vein (may be normal)
- level 3  closure with thrombus extension flush with SFJ
- level 4  closure with thrombus bulging into CFV
- level 5  closure with proximal thrombus extension adherent to adjacent wall of CVF past SFJ
- level 6  closure with significant proximal thrombus extension in CFV
 management
- level 3  most don't need treatment, only if high thrombotic risk
- level 4-5  anticoagulation until thrombus retracts to level 3 
- level 6  tx as a provoked DVT with anticoagulation x3 months

A different EHIT classification?? (#37)

 I  thrombosis to level of SFJ
 II  extension into deep system, cross-sectional area < 50%
 III  extension into deep system, cross-sectional area > 50%
 IV  occlusion of femoral or popliteal vv.
 anticoagulate EHIT III and IV

LYMPHEDEMA

Lymphedema
 classification based on etiology
- primary (cryptogenic)
» congenital - onset before age 1
› usually sporadic but can be secondary to Milroy disease (autosomal dominant VEGFR-3 mutation),
Noonan syndrome (PTPN11) mutation), Turner syndrome, Klinefelter syndrome, trisomy 21
» praecox - onset age 1-35
» tarda - onset after age 35
- secondary (acquired)
 differences from venous insufficiency
- venous edema does not affect toes and usually does not produce a positive Stemmer sign (thicken skin fold at
base of toe)
 management of severe unilateral lymphedema
- intensive reduction phase with manual lymphatic drainage (MLD), short-stretch bandaging, exercise, skin care
- maintenance phase with compression wraps, self-MLD, low pressure sequential pneumatic compression 
- elastic compression is ineffective if severe 

Venous vs. arteriovenous malformation

 venous malformation  may have  D-dimer due to localized coagulopathy 
 RADIATION SAFETY
VESAP 

Effective dose
 calculation of radiation exposure that reflects the risk of cancer formation 

Radiation exposure  exponentially with  distance  1/d2

Geometric magnification
 positioning patient closer to XR tube and farther from ii
  tube current,  scatter,  skin entrance dose

Bi-planar imaging
  total dosage if used for all imaging rather than only when necessary

Last image hold

 required by FDA for all fluoro machines 
 when operator removes foot from pedal, last image stays on screen  reduces fluoro time

Deterministic effect
 tissue reaction that occurs at a specific threshold dose of exposure
 skin injury is the most common

Stochastic effect
 occurs with no specific threshold dose
 probability increases with increasing dose
 ie, cancer, heritable changes in reproductive cells
 effective dose is the variable that most accurately predicts stochastic risk

Radiation induced skin injury

 deterministic effect of XR exposure
 2 Gray  transient erythema, develops within several hours to 2 weeks after exposure
 7 Gray  permanent epilation (hair loss), dyspigmentation, edema, several weeks after exposure
 10 Gray  dermal atrophy and telangiectasia, late consequence, rarely before 1 yr after exposure
 > 10 Gray  skin ulceration

Radiation induced cataracts

 caused by deterministic and non-deterministic effects
 appear on posterior capsule of lens (different than typical cataracts)
 maximal protection from a single method is via ceiling mounted Plexiglas shield (not lead glasses) 

Radiation and pregnancy

 nature and extent of deterministic effects on pregnancy depends on dose and trimester
- 100 mGy can be fatal to embryo during first trimester 
- 50 mGy is threshold for concern for congenital malformations per Ob/Gyn guidelines
 pregnant operators  lead should be 0.5-1 mm, stand 6 feet away, wear fetal dose badge under lead
 CRITICAL CARE - UNEDITED IMPORT

CARDIOVASCULAR

Preload = LV end-diastolic length linearly related to LVEDV and filling pressure NORMAL
Afterload = SVR CO (L/min) 4-8
MAP = CO x SVR CI (L/min) 2.5-4
Cardiac index = CO/BSA SVR 800-1400
Stroke volume = LVEDV - SLVESV determined by LVEDV, contractility, afterload PCWP 11 ± 4
Arterial O2 content (CaO2) = Hb x 1.24 x O2 sat + (PO2 x 0.003) CVP 7 ±2
O2 delivery = CO x CaO2 x 10 PAP 25/10 ± 5
O2 consumption (VO2) = CO x (CaO2 - CvO2) normal delivery-to-consumption ratio is 5:1 SvO2 75 ± 5

Causes of right shift on O2-Hb dissociation curve (O2 unloading)

 temp, ATP production, 2,3-DPG production, pH

Swan-Ganz
 should be placed in zone III (lower lung)
 relative c/i  prior pneumonectomy, LBBB
 hemoptysis after flushing Swan  PEEP to tamponade the pulmonary artery bleed, mainstem intubate non-affected side, can try Fogarty
balloon down mainstem of affected side, may need thoracotomy and lobectomy
 PVR (pulmonary vascular resistance) can only be measured by Swan (not by echo)
 distance to wedge
- R SCV 45 cm
- R IJ 50 cm
- L SCV 55 cm
- L IJ 60 cm

SvO2 (venous blood saturation), get from Swan

 SvO2 with shunting or extraction (ie, sepsis, cirrhosis, cyanide, hyperbaric O2, hypothermia, paralysis, coma, sedation)
 SvO2 with shunting or extraction (ie, hypoxemia, CO, malignant hyperthermia)
 blood with the lowest SvO2  coronary sinus (30%)

PCWP = ***
 may be thrown off by pHTN, aortic regurg, mitral stenosis, PEEP, poor LV compliance

A-a gradient

Intra-aortic balloon pump (IABP)

 inflates on T wave (diastole); deflates on P wave (systole)
 aortic regurg is a c/i to IABP
 place tip of catheter just distal to L subclavian 1-2 cm below the top of the arch
 used for cardiogenic shock (ie, after CABG, MI) or in pts with refractory angina as bridge to revascularization
 deflates during ventricular systole   afterload
 inflates during ventricular diastole   diastolic BP   diastolic coronary perfusion

Pacemakers

LVAD
 CRITICAL CARE - UNEDITED IMPORT

Pulse
Ox
 CRITICAL CARE - UNEDITED IMPORT

ECMO

 closed circuit, no venous reservoir (vs. cardiopulmonary bypass)

 basically some kind of VAD with oxygenator
 veno-venous
- use for pulmonary failure, must be reversible (ie, PNA, ARDS) or bridge to transplant
 veno-arterial
- use for cardiogenic shock, post-pump
 cannulation
- inflow/outflow are in relation to the pump, not pt
- peripheral cannulation
» ie, femoral v. (inflow) and femoral a. (outflow)
» oxygenated blood reaches heart via retrograde flow, so need R radial A-line for flow monitoring (L-side won't
tell you if you're crossing arch adequately)
» lower extremity needs distal perfusor
- central cannulation
» ie, RA (inflow) and aorta (outflow)
 CRITICAL CARE - UNEDITED IMPORT
 circuit -- 3 things can be controlled
- flow - controlled by RPMs
» usually 4-6 L/min
- FiO2
» usually leave at 100% but can be turned down if high PaO2
- sweep - controls CO2 exchange
» 0-6, usually at 1-3
» 0 = off, meaning oxygenator is also off
 weaning
- ***
 complications
- bleeding, coagulopathy, hemolysis
- renal failure - partly due to hemolysis
- loss of limb - distal perfusor tries to compensate for this
 troubleshooting
- chatter = suctioning against vessel wall
» either running flow too fast or volume is too low
 CRITICAL CARE - UNEDITED IMPORT
CARDIOVASCULAR DRUGS

Receptors
α1  vascular smooth m. constriction, gluconeogenesis, glycogenolysis
α2  venous smooth muscle constriction
β1  myocardial contraction and rate
β2  relaxes bronchial smooth m., relaxes vascular smooth m., insulin, glucagon, renin
DA  relax renal and splanchnic smooth m.

SHOCK

***

 calcium after massive transfusion  hypotension

EMBOLI

***

CO2 embolus
 1st - stop insufflation
 trendelenburg and L-side down (prevents any more propagation of CO2 into lungs)
 ventilate with 100% O2 (CO2 resorbed faster as it comes into equilibrium)
 CRITICAL CARE - PHARMACOLOGY
MECHANISM EFFECT
DRUG USE SIDE EFFECT / CONTRAINDICATIONS
α1 α2 β1 β2 DA SVR PVR contract HR
 septic or cardiogenic shock
phenylephrine    

norepinephrine 

epinephrine   

high dose low dose

dopamine   

high dose med dose low dose

dobutamine  

isoproterenol  

vasopressin V1 (smooth m.)

milrinone PDE1 inhibitor

ephedrine  catecholamine release

nitroprusside
 MISCELLANEOUS
Chlamydia pneumonia bacterium
 bug most associated with formation and rupture of atherosclerotic plaques 

Trauma exposures
 ***

Reperfusion syndrome  hyperkalemia, hypocalcemia, metabolic acidosis

Nutrition
 respiratory quotient for fatty acids, proteins, carbohydrates, etc.

Persistent sciatic artery

 presents with pulsatile buttock mass, no popliteal pulse, palpable pedal pulse
 originates from internal iliac, usually ends at popliteal
 needs to be treated due to risk for aneurysmal degeneration