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Out of the frying pan & into the fire

Out of the frying pan & into the fire. Dr Duncan Anderson Vascular Surgeon www.drduncananderson.co.za. The frying pan. Traditionally the surgeon has been based in the operating theatre Preoperative angiography was routinely performed by the radiologist. Case 1: Critical limb ischaemia.

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Out of the frying pan & into the fire

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  1. Out of the frying pan& into the fire Dr Duncan Anderson Vascular Surgeon www.drduncananderson.co.za

  2. The frying pan • Traditionally the surgeon has been based in the operating theatre • Preoperative angiography was routinely performed by the radiologist

  3. Case 1: Critical limb ischaemia • 61 year old male • Non-healing left ankle ulcer for 9 months • Risk factors: heavy smoker, hypertension & hypercholestrolaemia • Only left femoral pulse • Ankle brachial index: 0.46

  4. Case 1: Critical limb ischaemia • Catheter directed angiogram in the cathlab • Left femorodistal bypass to the posterior tibial artery • Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein

  5. Case 1: Critical limb ischaemia • Who should be referred to a vascular surgeon? • And which special investigations should be performed prior to referral?

  6. Who should be referred? • Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene • All patients with ankle brachial index <0.9 • Any diabetic, chronic renal failure patient or heavy smoker with absent pedal pulses

  7. Which special investigation? • Ankle brachial index (ABI) only • ABI 1.3-0.9 manage vascular risk factors • ABI 1.3-0.9 safely apply compression bandaging for venous stasis ulceration • No arterial duplex doppler ultrasound • No CT angiography • No MR angiography • No cathlab angiography

  8. The fire • Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography • Cathlab • Hybrid theatre • Offers a more goal directed therapy

  9. Case 2: Complex varicose veins • 36 year old female • Recurrent bilateral varicose veins • Vein surgery in 2005 • Pelvic congestion syndrome • Menorrhagia • Dyspareunia • Dysmenorrhoea

  10. Case 2: • Suspect pelvic /ovarian vein reflux • Recurrent varicose veins • Atypical varicose veins • Extensive groin varicosities • Vulvae varicosities • Pelvic congestion syndrome

  11. Case 2: Complex varicose veins • CT venography • Not a routine special investigation (timing critical) • Catheter directed venography

  12. Case 2: Complex varicose veins • Traditionally vein ligation & stripping • Endovenous laser or radiofrequency (VNUS) ablation • No groin wound • No thigh bruising • Less postoperative pain • Earlier mobilization

  13. VNUS ablation • Radiofrequency ablation • Cathlab or rooms • Ultrasound-guided • Tumescence infiltration • Immediate ambulation

  14. VNUS ablation • Tumescence infiltration • Local anaesthesia • Facilitates ablation by vein compression • Reduces risk of deep vein thrombosis • Creates “heat sink” to protect surrounding tissue

  15. VNUS ablation • Less pain & less bruising than laser ablation • Who should be referred to a vascular surgeon?

  16. Who should be referred? • Atypical distribution of varicose veins • Recurrent varicose vein • Associated chronic venous insufficiency (venous stasis dermatitis or venous ulcer) • Suspicion of pelvic/ovarian vein reflux • VNUS ablation for better cosmetic result, less pain & immediate mobilization

  17. Case 3: False aneurysm • 49 year old female • Painful swelling right groin 2 weeks after cathlab • BMI 40.4 • Large false aneurysm flush with common femoral artery (no neck)

  18. Case 3: False aneurysm • Direct surgical approach • Burst on skin incision • Direct digital control of 2cm defect in common femoral artery • Total of 4 unit blood transfusion

  19. Case 3: False aneurysm • Proximal control digitally through pelvis • Repaired with vein patch • Discharged after 6 days • High risk of wound & graft sepsis

  20. Case 3: False aneurysm • Negative surgical aspects • Additional open surgical procedure • Risk of anaesthesia • Prolonged hospital stay • Postoperative pain • High risk of wound & graft sepsis • Difficult mobilization

  21. Case 4: False aneurysm • 74 year old female • Painful right groin swelling 1 day after cathlab • BMI 32.2 • Dropped haemoglobin from 13g% to 9g%

  22. Case 4: False aneurysm • Long & narrow neck • Ultrasound-guided thrombin injection

  23. Case 4: False aneurysm

  24. Case 4: False aneurysm • Angioplasty balloon to arrest flow within aneurysm • Thrombin (factor IIa) converts fibrinogen to fibrin • Discharged within 48hrs

  25. “If all that you have is a hammer,then all that you’ll see are nails” VASCULAR SURGEON UROLOGIST ANAESTHETIST

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