VASCULAR SURGERY
Cerebrovascular Disease
CAROTID:
Presentation:
 Asymptomatic:
– Bruit (only 20%
hemodynamically
significant lesion)
– Screening prior to
other surgery
Presentation:

Symptomatic:
– TIA, Stroke
– Amaurosis fugax ipsilateral to carotid lesion
– Contralateral motor or sensory deficit
– Facial droop
– Dyshasia or aphasia
Investigations

Duplex Scan
 CT scan - confirm or r/o infarct
 CT/Angio – Confirm U/S plan
OR
 MRA – Similar to CT
Management

Asymptomatic
- Risk factor reduction (asa,statin,ACE)
– observation with regular duplex scans
– Antiplatelet agent and surgery more
controversial
– ACAS  60%  OR
– Canada  80% male, under 75 yrs or
 operate

Symptomatic:
– Carotid Stenosis  70%
– TIA, Small completed stroke
with minimal residual
neurologic deficit,
–  antiplatelet agent
+carotid endarterectomy
Arterial Aneurysms

Definition: 1.5-2x
diameter adjacent normal
artery.
 Ex. Aorta  3 cm
 True: All layers of
arterial wall dilated
 False: Aneurysm usually
consists of hematoma +/adventitia
Distribution of Aneurysms

Aorta: 90-95% are infrarenal

Peripheral: Popliteal most common,
2nd femoral

Visceral: uncommon, splenic (most
common)
Aortic Aneurysms
Risk factors: male, age  60 yrs, smoking,
COPD, FHx +ve, CAD, PVD, peripheral
aneurysms.
 Natural Hx: AAA  5 cm grow 0.3-0.5
cm/year
 Rupture rate:
–  5 cm - 1.5% over 5 yrs
– 5.5-5.9 cm - 25% over 1-5 yrs
– 6 cm - 35% over 1-5 yrs
– > 7 cm - > 75% over 1-5 yrs

AAA Presentation

Asymptomatic:
incidental finding on Px
or Radiologic Test
 Symptomatic:
ABD/BACK pain (leak
or rapid expanding)
 Rupture: 35% initial
presentation, Triad
ABD/BACK pain,
Hypotension, Pulsatile
Mass.
AAA Detection

Physical Exam - not
sensitive
 U/S ABD - highly
sensitive and specific
 CT / MRI - sensitive,
specific, but expensive
 Angio - not reliable
AAA Management
Indications for Surgery:
– risk of rupture > surgical
risk
– size  5 cm FEMALE
– > 5.5 cm MALE
– symptomatic
– ruptured
– rapid expansion
Observation with U/S q6
months if asymptomatic and
< 5 cm.
Lower Extremity Arterial
Disease
Acute Limb
Ischemia

Sudden onset of sxs/signs
 Severity presentation
depends on adequacy of
collateral circulation
 5 or 6 P’s: pain, pallor,
pulselessness, paralysis,
paresthesia, +/poikilothermia
CAUSES

Embolus

Thrombosis

Trauma
Embolus

Clot displaced from site of origin to
occlude a distant artery
 Most common site to lodge bifurcation
common femoral artery
 90% come from the heart (atrial
fibrillation, recent M.I.)
Thrombosis

Clot forms in situ in a previously diseased
vessel or bypass graft

Predisposing factors: Dehydration, CHF
or Hypercoagulable state
Acute Arterial Occlusion Presentation
Embolus
 Dramatic
presentation
(sudden onset)
 Opposite leg
normal pulses
 Source for
embolus: A.fib,
recent M.I.
Thrombosis
 Bland (well dev.
collaterals

Opposite leg abn.
Pulses
 Hx of chronic PVD,
ex. claudication
Investigations

Angiogram/CTA
– Gold Std
– Embolus (not always needed
prior to OR but shows abrupt
cut off of circulation, reverse
meniscus sign, no collaterals.
– Thrombosis - always needed,
shows tapering cut off, lots of
collaterals
Treatment
Embolus:
– Anticoagulate with Heparin
– Medical resuscitation
– Surgical embolectomy
– Consider Fasciotomies
– Post-op life long
anticoagulation Heparin 
Coumadin
Treatment

Thrombosis
– angiogram always
– thrombolysis +/- later surgical intervention
– Endovascular (angioplasty/stent)
– surgical bypass
– post-op antiplatelet agents
Compartment Syndrome

Especially after reperfusion
of the leg
  pressure within fascial
compartments >30mmHg.
 Symptoms/signs: Pain out of
proportion, pain on passive
flexion/extension, absent
pulses is a very late sign
 Treat: fasciotomies
Chronic Lower Limb
Ischemia
Presentation (symptoms):

Claudication = Reproducible pain in
the lower extremities on ambulation

Rest pain = Pain at rest in forefoot,
toes. Constant pain, worse at nite
Presentation (signs):

Claudicant +/- pulse deficits

Rest pain - pulse deficits, atrophic skin,
hair loss on toes

Tissue loss - ulcers (painful), gangrene
Presentation (signs):

Ankle brachial index:
– Normal  1
– Claudication 0.5 - 0.8
– Rest pain < 0.5
– Tissue loss < 0.3

ABI not always reliable in diabetic patient

Doppler signal present does not always ensure
adequate circulation
Leriche Syndrome:

Absent femoral pulses
 Impotence
 Buttock Claudication
Investigations:

Hx, Px, ABI

Blood Flow Lab - Duplex scan, exercise
testing, segmental pressure studies

Angiogram/CTA - Indicated prior to
intervention or diagnostic dilemma
Conservative Management

Modify risk factors - smoking cessation,
hyperlipidemia, diabetes
 Walking exercise program (Develops
collateral circulation)
 MEDS:
– All should be on antiplatelet: ECASA,
Clopidogrel, Ticlopidine, etc
– Statin
– Consider Pentoxifylline
INTERVENTION

Indications
– disabling claudication
– Critical ischemia:rest pain, tissue loss

Angioplasty + Stenting (best results for
proximal lesions ex: iliac lesion)
 Bypass
 Amputation
Aortic dissection

Definition: Intimal
tear leading to
creation of a false
passage way of blood
within the wall of the
aorta. Results in both
a true and false lumen
of the vessel
AORTIC DISSECTON

Most common catastrophic event of the
aorta

Consequences include:
– weakening of aortic wall and possible rupture
– interruption of blood supply to branches of
the aorta involved, resulting in end organ or
limb ischemia
Presentation

Classically older patient
with hx HTN and
sudden onset “tearing”
retrosternal chest + back
pain

On examination: HTN,
pulse deficits are
possible, murmur of
aortic regurgitation
Varicose Veins

Dilated saccular or
cylindrical superficial
veins

Different
appearances/severities
– Telangiectasia (spider
cluster extending out from
feeder vessel).
– Stem veins (saphenous)
– Reticular veins
(tributaries).
Classification

Primary - Superficial venous system only

Secondary - Deep system and or
perforators are also abnormal usually as
result of DVT, Pregnancy, Trauma
Predisposing Factors

Family history, female, 50 yrs or older,
multiparity, standing occupation, obesity,
BCP, DVT
Pathophysiology Primary Varicose Veins

Controversial: valvular incompetence,
wall weakness, A-V fistula
Presentation (symptoms)

Cosmetic appearance
 Pain, leg fatigue, burning, itching
 Swelling
 Symptoms made worse by prolonged
standing, relieved with elevation