Vascular Surgery

Presented By;
Mujahid Khan
Momina
Usman
Tehreema
From page 16 onwards...intro from each topic in this
presentation.
 Introduction;
• Vascular surgery is an umbrella term for a range of open
surgeries and minimally-invasive procedures involving your
blood vessels and lymphatic vessels.
• Blood vessels are a network of arteries,veins and capillaries
that carry blood to and from your heart and nourish your
organs and tissues.
• Lymphatic vessels help maintain the body's fluid balance,
absorb fats from the digestive tract, and provide immune
defense against microorganisms and disease.
• The vascular surgeons trained in the diagnosis and management of
diseases affecting all parts of the vascular system excluding the
coronaries and intracranial vasculature.
• Vascular surgeons can perform both traditional `open` surgeries and
minimally-invasive endovascular procedures.
• Vascular surgeons also are called to assist other physicians to carry
out surgery near vessels.
• Sometimes,lifestyle changes and medications manage your condition
but other times,you may need surgery to prevent the problem from
getting worse.
Vascular surgeries need interventions that;
• Repair damage to your blood vessels due to vascular
disease.
• Lower your risk of complications from these diseases.
• Create access to your blood vessels for medical
therapies like dialysis.
• It is important to note that vascular surgeons usually
don`t perform brain or heart procedures.
 History
• Early leaders of the field included Russian surgeon Nikolai
Korotkov,noted for developing early surgical
techniques,American radiologist Charles Theodore
Dotter,who is credited with inventing minimally-invasive
angioplasty [1964], and Australian Robert Paton,who helped
the field achieve recognition as a speciality.
• The most notable historic figure in vascular surgery is the
1912 Nobel Prize winning surgeon, Alexis Carrel for his
techniques used to suture vessels.
 Indications
• Because the blood vessels and lymphatic system play vital role in
carrying oxygen ,nutrients and waste throughout the body,they can be
involved in a wide range of medical conditions.Common conditions a
vascular surgeon treats include;
Aneurysm
Carotid artery disease
Deep vein thrombosis
Lymphedema
Peripheral arterial disease
Venous insufficiency
 Aneurysm
• An aneurysm is a buldge or widening in an artery.
• Aneurysm often happen in the aorta,the body`s main artery.
• High blood pressure can place increased pressure on the walls of the
blood vessels inside the brain,potentially increasing your chances of
developing aneurysm.
• When a bulge occurs in the part of the aorta that extends into the
abdomen, it`s called an abdominal aortic aneurysm.
• A rupture or tear in an abdominal aortic aneurysm can cause life-
threatening internal bleeding.
 Carotid artery disease
• Carotid artery disease happens when there is atherosclerosis,the
buildup of waxy plaque made of fat,cholesterol,and other substances
in the carotid arteries.
• These arteries ,located on each side of the neck,carry blood to the
brain.
• Blockage in the carotid arteries can increase the risk of stroke.
• Factors that increase risk of developing carotid artery disease are
diabetes mellitus,family history of stroke,high blood pressure,older
age,males,smoking or using alcohol and also trauma to your neck
increases its chances of developement.
 Deep vein thrombosis
• Deep vein thrombosis is a serious condition in which blood clots form
in the deep veins of the body, typically in the legs.
• DVT is dangerous because a clot — or piece of one — can travel to
the lungs (pulmonary embolism).
• Deep vein thrombosis doesn’t always cause symptoms.
• Factors that increase risk of developing DVT can be injury to a
vein,slow blood flow,increased estrogen,heart diseases,lung
diseases,cancer,inflammatory bowl disease.
• Family history also increases risk of DVT.
 Lymphedema
• Lymphedema is a condition in which lymph fluid builds up in the soft
tissues of the arms or legs.Usually filtered by the lymph nodes and
released into the bloodstream, lymph fluid can accumulate and cause
swelling when the nodes become obstructed.
• Lymph nodes act like a drain in your sink so if the drain is clogged,the
fluid cannot drain.
• Lymphedema can be caused by
trauma,cancer,cellulitus,radiotherapy,infection,lymph node
removal,cardiovascular disease,obesity,parasites and venous diseases.
 Peripheral arterial disease
• Peripheral arterial disease — also called peripheral vascular disease
(PVD) — is when there is atherosclerosis in the arteries anywhere
outside of the heart and brain.
• Typically found in the legs or (less often) arms, PAD can cause leg pain
during walking,hair loss on your legs and feet,shiny skin,erectile
dysfunction in men,muscles in legs starts shrinking and wasting and
ulcers on your feet and legs,which do not heal.
• It`s usually caused by a build-up of fatty deposits in the walls of the
leg arteries.
 Venous insufficiency
• Venous insufficiency is when the veins aren’t able to keep blood
flowing back to the lungs and heart. This condition is due to broken
valves that allow blood to flow backward, away from the heart and
lungs. Venous insufficiency can lead to problems such as:

• Varicose veins: Veins that are twisted and swollen so that they’re
visible just under the skin, often on the legs.
• Venous ulcers: These open sores or wounds typically occur on the
legs, above the ankles.
Arterial stenosis management
• Investigations : Doppler’s ultrasound And ECG
• Angiography: it involves the injection of radio opaque dye into the
arterial tree by a percutaneous Catheter method called Seldinger
technique usually involving femoral artery ( because 70% of Arterial
stenosis occurs in superficial femoral artery that causes calf
claudication)
• Walking : will lead to improvement of symptoms – weight loss – diet
– smoking cessation
• Drugs : statins and antiplatelet agents
Surgical management of arterial stenosis
• Transluminal angioplasty: by inserting a balloon catheter into an
artery and inflating it within a narrowed or blocked area.
• If the vessel fail to stay adequately dialated it may be possible to hold
the lumen open using a metal stent
• Superficial femoral artery disease can be treated by femoropopliteal
bypass
Aortobifemoral grafting
Acute Arterial emboli
• Mostly occurs in brain causing TIA and Retinal artery where it causes
Amaurosis fugax ( fleeting blindness (lasting for short term ) and in
mesenteric vessels causing possible gangrene of loop on intestine

Management: immediate administration of heparin 5000 U

• Embolectomy and thrombolysis
• For compartment syndrome ------- Fasciotomy
Deep venous thrombosis
• Investigations: Doppler ultrasound
• For PE --- CT pulmonary angiogram ( gold standard)
• MRI
• Nonsurgical prophylaxis: Heparin and warfarin (10mg on day 1 ,,
10mg on day 2 and 5mg on day 3 )
• Thrombolysis should be considered in patients with an iliac vein
thrombosis ( Tpa is administered into popliteal vein or by direct
puncture in the groin
Venous injuries
Types of venous repairs
a) Lateral suture
b) Patch graft
c) Carrel triangulation technique
d) Pan graft
e) Spiral graft
Varicose veins management
• Investigations: Duplex ultrasound
• Compression hosiery : External pressure to improve deep venous
return. (Compression stockings)
class1 stocking: 14-17mm of hg.
class 2 : 18-24mm hg
Class 3 : 25-35mm hg
• Ultrasound guided foam Sclerotherapy: injecting detergent directly
into superficial veins ( sodium tetradecyl sulphate)
 Aneurysms
Signs and symptoms
Ruptured aneurysm : nausea, vomiting , stiff neck , blurred or double
vision, sensitivity to light , seizure, loss of consciousness and confusion.
Leaking aneurysms: extremely severe headache (WHOML).
Unruptured aneurysms: pain above and behind one eye, a dilated pupil,
a change in vision or double vision, numbness of one side of face.
Investigation: angiography with x ray
Angiography with scan (CT angiography and MRA)
MRA for unruptured aneurysms and Ct for ruptured aneurysms
Lp for ruptured aneurysms.
Screening…..
 Aneurysms
Type of aneurysms repair(surgeries)
. Open aneurysms repair
. Endovascular aneurysms repair
. Hybrid aneurysms repair
 Lymphedema
• Signs and symptoms
• Swelling in part of the body
• Skin feeling tight or hard, change in texture, looking red
• New aching, tingling, numbness or other discomfort in the area
• Less moment or flexibility in near by joints
• Trouble fitting your arm in to the jacket or sleeve or trouble fitting into or
buttoning your pants
• Collar, rings, watches and or bracelets feeling tight even though you have
not gained weight
• Breast cancer, head and neck area
• Kaposi-stemmer sign
 Lymphedema
• Clinical Investigation
• Contralateral leg
• Leg-o-meter (ankle or calf)
• Tap measure (not reliable)
• Water displacement volumetry
• Tonometry (prognosis)
• Bioelectrical impedance
• Edema tester
 Lymphedema
• Radiologic investigation
• Lymphangiogram
• Lymphoscintigram (gold standard)
• Ultrasound
• Duplex ultrasound
• Computed tomography
• Magnetic resonance imaging
 Lymphedema
Type of surgeries
• Liposuction
• Lymphaticovenous anstomosis
• Lymphovenous transplant
• Charles procedure (skin graft)
•
COMPLICATIONS
Complications attending vascular surgery can be classified into 5
categories:
1. Bleeding
2. Clotting
3. Neurologic injury
4. Infection
5. Renal Failure

From the Department of Surgery, The Jhons Hopkins University School

of Medicine, Baltimore, Maryland
BLEEDING / HEMORRHAGE
1. VENOUS:
Blunt and rough dissections are the major causes of intraoperative
venous hemorrhage. For example, the aorta has been described aptly
as an artery surrounded by veins. So in rush to control aortic
hemorrhage, the tendency is to try to pass a finger around these
vessels to clamp them "securely".
2. ARTERIAL:
The most devastating source of arterial hemorrhage occurs when the
aorta simply will not hold stitches. This may happen in patients with
known connective tissue disorders, such as Marfan's syndrome. It is
much more comman in patients with atherosclerosis in which intima
and most of media is soft and flimsy.
CLOTTING
It is rare. Chances of bleeding is higher than clotting.
ATHEROEMBOLISM:
The very worst thrombotic problem is atheroembolism. This occurs
when clamps are placed on an aorta containing cheesy atheromatous
debris. This debris may be washed into kidneys and gut during
occlusion, but more often millions of particles are washed into the
pelvis and legs when the clamp is released. To avoid this surgeon
should manually compress the segment of artery to be clamped.
NEUROLOGIC INJURIES
Many important nerves run in close proximity to arteries the surgeon
frequently is called on to repair, so injury to the nerves is also a
possibility.
INFECTION
Vascular infections often develop during or following vascular surgery,
particularly with procedures involving the bypass, repair or
replacement of a blood vessel. For example, staphylococcus bacteria
located on a patient's skin could transfer to the graft being inserted and
lead to a staph infection.
RENAL FAILURE
Postoperative renal failure is a dreaded vascular complications,
occuring most often in the context of shock, impaired renal function, or
after surgical procedures producing renal ischemia. Because the
surgeon does not have the control of all these variables, he has to act in
role of a "damage control".