Vascular Surgery Back to Basics

1. Vascular SurgeryBack to Basics Andrew B Hill MD FACS FRCS Vascular and Endovascular Surgery The Ottawa Hospital

2. OUTLINE • Acute limb ischemia • Claudication • Critical limb ischemia • Aortic Aneurysm • Aortic dissection • Varicose veins • Chronic venous insuffciency • Superficial thrombophlebitis Acute Limb Ischemia

3. Mrs. Whitelegg • ID: • 75 yo lady • Active - walks her dog ~2 kms daily • has not needed to see a doctor in the last 10 years. Acute Limb Ischemia

4. Mrs. Whitelegg PMHx/PMSx: remote TAH-BSO social smoker quit in the 1960’s No: DM HTN hyperlipidemia Acute Limb Ischemia

5. Mrs. Whitelegg • HPI: • watching TV • sudden onset of numbness in her right leg - “like it went dead” • Unable to walk • constant, severe pain eventually involving the entire right leg. • Called amblance Acute Limb Ischemia

6. Mrs. Whitelegg What is the diagnosis? Acute Limb Ischemia

7. Mrs. Whitelegg • Acute limb Ischemia: • abrupt cessation of arterial blood flow • hypoperfusion of tissue • threatened limb viability Acute Limb Ischemia

8. Mrs. Whitelegg Vital Signs BP:140/90 mmHg HR: 150 bpm irregularly irregular Afebrile Acute Limb Ischemia

9. Mrs. Whitelegg • Exam Normal heart sounds Chest clear IPPA No pulsatile masses in her abdomen No carotid, abdominal or femoral bruits Acute Limb Ischemia

10. Mrs. Whitelegg Exam Pulses: Left: + femoral, + politeal, + DP, + PT Right: - femoral, - popliteal, - DP, - PT Acute Limb Ischemia

11. Mrs. Whitelegg Exam Normal heart sounds good a/e bilat No pulsatile masses in her abdomen No carotid, abdominal or femoral bruits Pulses: L: + femoral, + politeal, + DP, + PT R: - femoral, - popliteal, - DP, - PT R foot is colder and paler than L Decreased sensation in R foot Able to move toes but difficulty with plantar and dorsi flexion Absence of trophic changes in her lower extremities (no hair loss, thickened nails, or thin, flaky or shiny skin) Acute Limb Ischemia

12. Mrs. Whitelegg Exam R foot is colder and paler than L Decreased sensation in R foot Able to move toes but difficulty with plantar and dorsi flexion Absence of trophic changes in her lower extremities (no hair loss, thickened nails, or thin, flaky or shiny skin) Acute Limb Ischemia

13. Mrs. Whitelegg • What are the 6 P’s of Acute Limb Ischemia Acute Limb Ischemia

14. Mrs. Whitelegg 6 P’s of Acute Limb Ischemia Pain Palor Polar/poikilothermia Paraesthesia Paralysis Pulselessness Acute Limb Ischemia

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

16. Mrs. Whitelegg • Your working diagnosis is acute limb ischemia. • You order CBC, electrolytes, BUN, Cr, PTT/INR (all of which comes back normal), type and cross-match blood, and a saline infusion is started. • CXR is unremarkable • ECG is as follows: Acute Limb Ischemia

17. Mrs. Whitelegg • What is the most likely etiology of ALI in Mrs. Whitelegg? • Cardiogenic embolism Acute Limb Ischemia

18. Mrs. Whitelegg What in her history and physical supports this diagnosis? lack of atherosclerotic risk factors no previous claudication (she walked her dog 2 km/day) atrial fibrillation normal left extremity pulses Acute Limb Ischemia

19. Mrs. Whitelegg Based on her physical examination, what is the highest point of obstruction of arterial flow? R ileo-femoral region Acute Limb Ischemia

20. Mrs. Whitelegg How long can a limb be without blood flow before irreversible tissue damage ensues? 4-6 hrs Acute Limb Ischemia

21. Mrs. Witelegg • What is the surgical management of this condition? • R femoral embolectomy • Can we proceed to the OR without any imaging studies? If not what studies can be perfomed? • Because of the classic history and physical findings, and because of the presence of class 2b ischemia, immediate surgery is indicated without delay for imaging. • Angiography can be performed in certain conditions of ALI • when the suspected etiology is arterial thrombosis (i.e. in preparation for bypass surgery) • when the patient has class 1 or 2a ischemia Acute Limb Ischemia

22. Mrs. Witelegg • What medical therpay is available for ALI and when is it indicated? • Lytic therapy (i.e. with t-PA) is used to dissolve the clot. It is a good option in the setting of acute arterial or graft thrombosis. It is not indicated in the setting of trauma or when the patient can not wait more than 24-48 hrs, as the therapy requires that period of time for clot dissolution. ( i.e. class 1 or early 2a ischemia) • IV Heparin will not dissolve the clot but will prevent further propagation, and is only indicated if there is a delay to surgery Acute Limb Ischemia

23. Mrs. Witelegg • The patient is booked for emergency embolectomy • Under local anaesthesia, a small incision is made over the R groin. The femoral artery is exposed and controlled with vessel loops. A small arteriotomy is made and the clot is removed proximally and distally using a fogarty balloon embolectomy catheter. • The arteriotomy is repaired and the foots “pinks up” after blood flow is returned. There is a palpable DP and PT pulse. • The patient is returned to the recovery room. Acute Limb Ischemia

24. Mrs. Witelegg • At 3 am you get paged by the recovery room nurse. Mrs. W is complaining of significant pain in her leg, it is more swollen and the DP and PT are no longer palpable. • In addition, her urine output has diminished and she is peeing out dark urine which tested positive for “blood” on the urine dipstick. Acute Limb Ischemia

25. Mrs. Witelegg • What is happening to Mrs. W? • Reperfusion syndrome: occurs as a result of blood flow going back into previously damaged tissue, causing rhabdomyolysis and compartment syndrome.. • Rhabdomyolysis: Liberated myoglobin from dead muscle cells enters the blood stream resulting in renal tubular obstruction and direct nephrotoxicity causing renal failure. Myoglobinuria is a false positive on the urine dipstick test for blood. • Compartment syndrome: Free oxygen radicals are created with reperfusion. These result in increased tissue edema, with in the limited facial compartments of the lower leg, this further decreases capillary blood flow and worsens the ischemia and tissue damage, causing further edema. Pain out of proportion, pain on passive stretch and high pressures in the compartments suggests compartment syndrome. Acute Limb Ischemia

26. Mrs. Witelegg • How should reperfusion syndrome be managed? • Compartment syndrome is a surgical emergency and is managed by 4-compartment fasciotomies. • Rhabdomyolysis should be managed with aggressive IV fluids, diuresis and alkalinization of urine. Acute Limb Ischemia

28. AORTIC DISSECTION

29. Definition • spontaneous tear in aortic intima allowing blood to be driven between the aortic intima and media • acute < 2 weeks • chronic > 2 weeks Aortic Dissection

30. Classification • DeBakey • Type I - involves ascending and descending aorta • Type II - ascending aorta only • Type IIIA - descending thoracic aorta • Type IIIB - Type IIIA plus abdominal aorta • Standford • Type A - ascending aorta and aortic arch; emergency • Type B - aorta distal to subclavian artery; emergency surgery if complications of dissection Aortic Dissection

31. Etiology • HYPERTENSION, usually uncontrolled • TRAUMA, usually deceleration injury (falls, MVAs) • other: cystic medial necrosis, atherosclerosis, connective tissue disease (Marfan’s syndrome, Ehlers-Danlos syndromes), congenital conditions (coarctation of aorta, bicuspid aortic valves, PDA), infection, arteritis (Takayasu’s) Aortic Dissection

32. Epidemiology • incidence 5.2 in 1,000,000 • male:female = 3:1 • small increased incidence in African-Canadians (related to higher incidence of hypertension) • lowest incidence in Asians Aortic Dissection

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

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

35. Treatment • Type A • EMERGENCY CARDIAC SURGERY • may require putting patient on pump, hypothermic circulatory arrest, valve replacement, coronary re-implantation of aortic root • resection of intimal tear, reconstitution of flow through true lumen, replacement of the affected aorta with graft • Type B • MEDICAL MANAGEMENT • very rarely urgent operation for complications (expansion, rupture, gut/leg/renal ischemia, ongoing pain Aortic Dissection

36. AORTIC ANEURYSM

37. Definition • localized dilation of an artery that is 2 x its normal diameter • true aneurysm: involving all vessel wall layers • false aneurysm: disruption of aortic wall with containment of blood by some layers of the aorta or a fibrous capsule made of surrounding tissue Aortic Aneurysm

38. Aortic Aneurysm Aortic Aneurysm

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

40. Epidemiology • incidence 5 to 32 per 100,000 for AAA • high risk groups: • 65 years and older • male:female = 4:1 • smokers • peripheral vascular disease, CAD, CVD • family history of AAA Aortic Aneurysm

41. Clinical Features • Vast majority ASYMPTOMATIC • RUPTURE • back pain • hypotension/syncope • pulsatile abdominal mass • ~100% mortality if untreated Aortic Aneurysm

42. Investigations • abdominal US (100% sensitive) • CT • Aortogram (false negative normal lumen size due to thrombus formation) Aortic Aneurysm

43. Treatment • Risk of rupture depends on size • <5 cm <5% / yr • 5-6 cm 10% / yr • 6-7 cm 15-20% / yr • >7 cm >20% / yr • Risk of dying from aneurysm surgery = ~5% Aortic Aneurysm

44. Treatment • Operate when • AAA reaches 5.5 cm in an otherwise healthy individual • >5 mm expansion in 6 months • symptomatic AAA • Rupture • contraindications: life expectancy < 1 year, terminal disease (cancer), significant co-morbidities (recent MI, unstable angina), severe dementia, advanced age Aortic Aneurysm

45. Treatment: Surgical • Surgical options: • open surgery with graft replacement • Endovascular aneurysm repair Aortic Aneurysm

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

47. CLAUDICATION

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

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

50. Investigations • Ankle Brachial Index • Angiogram