Surg Med - Vascular Surgery - Exam 3

Atherosclerosis

MCC of vascular disease

Chronic inflammatory disease of arteries characterized by plaque formation within the arterial wall

Can block blood flow 

Create clots/thrombi

Atherosclerosis Modifiable RF

Smoking

Obesity

Sedentary lifestyle

Chronic medical conditions: diabetes, HTN, hyperlipidemia

Atherosclerosis Non-Modifiable RF

Age

Sex

Family history

Atherosclerotic Plaque Formation - Anatomic Sites

Carotid bifurcation

Coronary arteries

Aortic bifurcation

Femoral arteries

Popliteal arteries

Why? Branch points and turbulent flow

Atherosclerotic Plaque Formation Comp

Stroke

Buttock claudication/leg ischemia

MI

PAD Surgery Indications

Lifestyle limiting claudication

Rest pain

Tissue loss

Failed endovascular treatment

PAD - Bypass

A surgical procedure that creates an alternate route for blood flow around a blocked artery

Ankle-to-Brachial index

A non-invasive sensitive and specific tool that measures ankle systolic pressure/brachial systolic pressure

Normal >0.90

<0.40

what is a severe ABI?

Femoral-Popliteal Bypass

Femoral artery → popliteal artery

Indications: Significant blockage in: Superficial femoral artery, Above-knee popliteal artery

Causing: Lifestyle limiting claudication, Rest pain, Tissue loss

Femoral-Distal Bypass

Femoral artery → tibial/pedal artery

Femoral-Distal Bypass Indications

More extensive disease involving:

-Femoral artery

-Popliteal artery

-Tibial arteries

Usually seen in:

-Advanced PAD

-Critical limb ischemia

-Diabetic patients

-Tissue loss

-Non-healing wounds

Above Knee Amputation

Higher energy expenditure with prosthesis

Removal of leg above knee

Above Knee Amputation Indications

Tissue loss extends above calf

Severe infection

Poor blood flow preventing BKA healing

Failed BKA

Above Knee Amputation Disadvantages

More energy required for walking

Harder rehabilitation

Worse prosthetic function

Below Knee Amputation

Most functional major amputation

Removal of lower leg while preserving knee

Below Knee Amputation Indications

Severe infection

Extensive tissue loss

Failed revascularization

Non-salvageable foot

Transmetatarsal Amputation

Forefoot level

Amputation through metatarsal bones

Transmetatarsal Amputation Indications

Multiple non-salvageable toes

Extensive forefoot infection

Forefoot gangrene

Toe Amputation Indications

Gangrenous toe

Osteomyelitis limited to toe

Small areas of non-salvageable tissue

Toe Amputation Advantages

Maximum preservation of function

Fastest recovery

Toe Amputation Limitations

Must have adequate blood flow to heal

Ray Amputation

Removal of toe + metatarsal

Indications:

-Infection extends beyond toe

-Gangrene involves metatarsal region

Surgical Amputation Indications

Non-salvageable tissue

Severe infection

Gangrene

Failed revascularization

Acute Arterial Occlusion S/S

Pain

Pallor

Pulselessness

Poikilothermia

Paresthesia

Paralysis

Sudden limb ischemia threatening limb viability

Acute Arterial Occlusion Tx

Thrombectomy/embolectomy (remove clot using catheter)

Catheter directed thrombolysis (clot dissolving medication delivered directly into clot)

Abdominal Aortic Aneurysm

Repair before rupture whenever possible

Symptomatic aneurysm, rupture, or diameter large enough to carry significant rupture risk

AAA Tx

EVAR (endovascular stent graft placed through femoral arteries)

Open aneurysm repair (replace aneurysmal segment with synthetic graft)

Mesenteric Ischemia S/S

Pain out of proportion to exam

Acute bowel ischemia or severe chronic symptoms from inadequate blood flow

Mesenteric Ischemia Tx

Mesenteric artery stenting

Bypass

Carotid Artery Dz/Occlusion

Stroke prevention

Significant carotid stenosis, especially if associated with TIA or stroke symptoms

Carotid Artery dz/occlusion tx

Carotid endarterectomy (surgical plaque removal)

Carotid artery stenting

Subclavian Steal Syndrome

Arm "steals" blood from posterior circulation

Symptomatic arm ischemia or vertebrobasilar symptoms (dizziness, syncope)

Subclavian Steal Syndrome Tx

Subclavian artery angioplasty/stenting

Carotid-subclavian bypass

Renal Artery Stenosis

Secondary HTN

Selected patients with resistant HTN, recurrent flash pulmonary edema, or progressive renal dysfunction

Renal Artery Stenosis Tx

Renal artery angioplasty with stenting

Splenic Artery Aneurysm

Most common visceral aneurysm

Symptomatic aneurysm, enlarging aneurysm, pregnancy, or high rupture risk

Splenic Artery Aneurysm Tx

Endovascular coil embolization/stent graft

Surgical ligation/resection

Popliteal Artery Aneurysm

Often feared for thrombosis rather than rupture

Symptomatic aneurysm, thromboembolism, limb-threatening ischemia, or aneurysm meeting repair criteria

Popliteal Artery Aneurysm Tx

Bypass with exclusion of aneurysm

Endovascular stent or graft placement