Vascular Surgery: A Comprehensive Guide to Procedures and Treatments

Antembolic IVC Filter

Indication

Contraindications

• Hemorrhage
• Major surgery
• Multiple trauma
• Internal bleeding
• Intracranial neoplasm
• Pregnancy

Technique

• Fast 4-6 hours before procedure
• Antibiotic Prophylaxis
• Neck Skin asepsis
• Give Local Anesthesia
• Puncture anterior wall of vein (US)
• Evaluate the wire
• Guide the wire into IVC
• Place the sheath
• Remove wire + ensure luminal location
• Cavography to ensure IVC patency, size, locate Renal Vein

Post-op

• Activity/Diet Rest
• Antibiotic therapy
• NSAIDs
• Warfarin
• Venous protector

Indications for Reconstructive Arterial Surgery

• Claudication interfering with lifestyle
• Stage III
• Stage IV
• After 3 non-effective courses of treatment with medications in stage II
• ≤ 0.5 ankle-brachial index

Embolectomy and Thrombectomy

Thrombectomy

• Catheter Aspiration Thrombectomy: Thrombus Removed Using Suction
• Mechanical thrombectomy: thrombus broken up into small pieces

Embolectomy

• Catheter embolectomy: Balloon embolectomy
• Surgical embolectomy: incision into vessel surgical removal of clot

Indications

• Massive PE
• Contraindication for fibrinolytic therapy
• Arterial embolism
• Stroke

Indications for Invasive PAD Treatment

Indications

• Rest pain
• Ischemic ulcer or gangrene
• Short claudication if medication management is insufficient

Surgical Bypass

• Redirect blood flow around a blocked vessel via new pathway graft
• Autologous vein or artery graft
• Consider prosthetic graft

I- Femoropopliteal bypass

• Venous reverse in situ
• Configuration end to end anastomoses

II- Aortoiliac reconstruction

• Aortobifemoral/iliofemoral bypass
• Prosthetic grafts
• Leriche Syndrome (occlusion of both iliac arteries)

Post-op

• Anticoagulation for life

Carotid Endarterectomy

Indication

• Short occlusion 3-9cm
• To prevent stroke
• Superior mesenteric artery endarterectomy for abdominal angina
• Renal artery endarterectomy in case of renovascular hypertension

Technique

• Artery opened longitudinally
• Arterosclerotic plaques removed
• Prolene suturing of artery

Indication for Patch

• If plaque >2cm into internal carotid

Abdominal Aortic Aneurysm (AAA)

Definition

AAA: Local aortic dilation > 30 mm

Risk Factors

• Age
• Male Gender
• History of Arteriosclerosis
• Smoking
• Hypertension
• History of AAA

Epidemiology

• 80 million people 60 years + in Western EU are at risk
• 12th leading cause of death in the West
• Silent killer because of being asymptomatic a lot of the time
• 4-8% of male population aged 65+

Classification

1. Infrarenal: Dilation occurs below Renal vessels
2. Suprarenal: dilation involves one of visceral arteries but does not extend to chest
3. Pararenal: Renal but not superior mesenteric arteries arise from aneurysm
4. Juxtarenal: dilation at the junction of renal artery

Indication for Surgery

• AAA diameter > 5.5cm
• Symptomatic AAA
• Ruptured AAA

Diagnosis

• Physical exam: palpation of abdomen
• Ultrasound
• Aortography
• CT + MRI (gold standard)

Treatment

Surgery > 5.5cm

Acute Limb Ischemia

Definition

Sudden occlusion of an artery

Etiology

• 1.5 per 10,000 in a year
• 3 main groups:
  1. Thrombosis in situ (60%): Atheroma in artery rupture & thrombus forms on atheromatous plaque cap
  2. Embolization (30%): thrombus from proximal source travels distal to occlude artery
  3. Trauma: 10%

Classification

• Class I: Non-threatening Extremity, elective revascularization may be necessary
• Class II: Threatened Extremity, revascularize to prevent tissue loss
• Class III: Ischemia has progressed to infarction, salvage of extremity is impossible

Clinical Features

• Pain
• Pallor
• Paralysis
• Pulse deficit
• Paresthesia
• Poikilothermia

Treatment

• Initial 10,000 U heparin
• Primary intervention with Fogarty balloon catheter embolectomy
• Bypass surgery possible
• Endarterectomy with or without angioplasty
• Graft interposition end to end anastomoses

Surgical

1. Catheter embolectomy:
   • Thrombus is extracted by Fogarty catheter
   • Abdominal aorta
   • Artery opened
   • Fogarty catheter insertion & removal
   • Heparin 5,000 U in artery
2. Bypass surgery:
   • Acute thrombosis
   • 50-99% stenosis
   • In saphenous magna vein
3. Amputation:
   • Irreversible ischemia
   • Permanent tissue damage

Critical Limb Ischemia

Definition

Advanced stage of PAD & defined by triad (Ischemic rest pain / Arterial (-) / Ulcer and gangrene)

• Critical Limb Ischemia (CLI) is a severe obstruction of the arteries decreasing blood flow to the extremities (hands, feet and legs)
• Progressed to the point of severe pain and even skin ulcers or sores.
• The pain caused by CLI can wake up an individual at night (rest pain).

Classification

• Stage:
  • I: Asymptomatic or subclinical symptoms (paresthesia, cold extremity)
  • IIa: Intermittent claudication after > 200m
  • IIb: Intermittent claudication < 200 m
  • III: Pain at rest, especially at night
  • IV: Ischemic ulcer or gangrene

Treatment

I- Angioplasty

• Small balloon inserted through puncture in groin
• Inflated to open artery
• Cutting balloon: Microblades to cut off the plaque reducing force to dilate
• Cold balloon: Nitric Oxide, freezes the plaque, Scar Tissue

II- Stenting

• Insertion of metal mesh tube that provides a scaffold which is left in place after balloon angioplasty
• Balloon expanded: to expand stent (less flexible)
• Self expanding: compressed stent that can self expand (flexible)

III- Laser Atherectomy

• Plaque is vaporized by tip of laser

IV- Directional Atherectomy

• Catheter with rotating blade to remove plaque from artery

Invasive Surgical Treatment: Surgical Bypass

• Redirect blood flow around a blocked vessel via new pathway graft
• Autologous vein or artery graft
• Consider prosthetic graft

I- Femoropopliteal bypass

• Venous reverse in situ
• Configuration end to end anastomoses

II- Aortoiliac reconstruction

• Aortobifemoral/iliofemoral bypass
• Prosthetic grafts
• Leriche Syndrome (occlusion of both iliac arteries)

Post-op

• Anticoagulation for life

PAD Treatment (Critical Limb Ischemia)

Definition

Chronic narrowing of blood vessels, mainly in legs

Lifestyle Modifications

• Stop smoking
• Exercise
• Antiplatelet agent (aspirin 75 mg, clopidogrel 75 mg)
• Reduce cholesterol
• Diagnosis & treatment of diabetes
• Medications: Cilostazol & Pentoxifylline

Endovascular Treatment

I- Angioplasty

• Small balloon is inserted through the puncture in the groin
• Balloon is inflated using saline solution to open the artery
• Cutting balloon: Embedded microblades cut off surface of plaque
• Cold balloon: Inflation with Nitric Oxide, which freezes the plaque, generating scar tissue

II- Stenting

• Insertion of metal mesh tube that provides a scaffold which is left in place after balloon angioplasty
• Balloon expanded: A balloon is used to expand the stent - these stents are stronger but less flexible
• Self-expanding: Compressed stent that extends by themselves upon release - Flexible

III- Laser Atherectomy

• Small bits of plaque are vaporized by laser

IV- Directional Atherectomy

• Catheter with rotating cutting blade to destroy plaque

Surgical Bypass

• Redirect blood flow around a blocked vessel via new pathway graft
• Autologous vein or artery graft
• Consider prosthetic graft

I- Femoropopliteal bypass

• Venous reverse in situ
• Configuration end to end anastomoses

II- Aortoiliac reconstruction

• Aortobifemoral/iliofemoral bypass
• Prosthetic grafts
• Leriche Syndrome (occlusion of both iliac arteries)

Deep Vein Thrombosis (DVT)

Treatment

I- Anticoagulation

• Systemic thrombolysis

II- Surgical

III- Endovascular

• Stenting
• Percutaneous thrombectomy
• Local thrombolysis

IV- Thrombolysis

• Indications: Acute iliofemoral DVT, < 7 days from the onset
• Advantages: Efficiency/protection from valve insufficiency
• Contraindications: Acute MI / stroke < 1 month

V- Long Term (Prevention)

• Anticoagulation: Warfarin / Heparin

Invasive: Indication

• Phlegmasia
• Symptomatic IVC thrombosis
• Poor anticoagulation response
• Acute proximal ilio-femoral DVT
• Thrombolysis: Indications: Acute iliofemoral DVT, < 7 days from the onset of symptoms

Post-op

• Remains in bed rest
• Monitor vital signs
• Monitor puncture sites (catheter oozing or enlarged hematoma)
• IV access for blood sampling
• 6-hour interval