Ebook Vascular surgery: Part 1

OXFORD MEDICAL PUBLICATIONS

Vascular Surgery


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Oxford Specialist
Handbooks in Surgery

Vascular
Surgery
Second Edition

Linda Hands

Associate Professor in Surgery
Nuffield Department of Surgery
University of Oxford, John Radcliffe Hospital
Oxford, UK

Matt Thompson
Professor of Vascular Surgery, St Georges Vascular
Institute, St George’s Hospital, London, UK

1


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v

Preface
Vascular surgery is an evolving specialty which has to embrace the current
developments in endovascular surgery while looking to future changes in

training that may encompass more of the ‘medical’ aspects of vascular disease. Nevertheless, open surgical techniques still play a large role in the
management of the vascular patient and will do so for some time to come.
The vascular surgeon needs to be a physician who can operate but who also
knows when to operate.
This book is designed to give detailed guidance on the work-up, perioperative management, and operative details for patients undergoing vascular surgery. These details reflect the practice of the chapter authors; they
are not intended as the only possible approach, and, in many cases, there
are alternatives. The book includes both endovascular and open procedures for each condition where they are available and gives advice on the
use of each. OPCS 4.7 (204) codes are included for each procedure so
that they become familiar to the surgical team in an environment where an
accurate recording of activity is becoming essential.
The book is designed primarily for the training grade doctor to carry in
their pocket on the ward, in clinic, and in the operating theatre. It is designed
for quick reference and rapid reading and will help resolve uncertainties on
the ward and prepare the trainee for their role in theatre, whether as prime
operator or as assistant. It should also be helpful to F and F2 doctors
involved in the care of vascular patients by providing background on the
disease, details of ward management, and an idea of what happens in theatre. The trainee vascular anaesthetist will find useful detail of anaesthetic
management but also of what is going on at the other end of the table.
Similarly, trainee interventional radiologists, vascular nurses, and vascular
technologists will all find that a broader appreciation of vascular patient
management can be obtained from this book.


vi

Contents
Preface╇ v
Detailed contents╇ viii
Contributors╇ xiv
Symbols and abbreviations╇ xv

 Arterial and venous disease
2 Arterial history and examination
3 Venous history and examination
4 Investigation of arterial and venous disease
5 Non-operative treatment: arterial
and venous disease
6 Management of complex leg ulcers
7 Perioperative management of ischaemic
heart disease
8 Anaesthesia for vascular surgery
9 Managing coagulation and bleeding
0 Infection prophylaxis and treatment
 Graft material in bypass grafting
2 Techniques of open vascular surgery
3 Abdominal aortic surgery
4 Thoracic aortic surgery
5 Infrainguinal revascularization
6 Lower limb amputations
7 Vascular surgery of head and arm
8 Surgical revascularization of kidneys


2
3
39
49
55
63
87
07

23
3
39
73
27
227
27
289
33


vii

CONTENTS

 9 Revascularization of the gut
20 Extra-anatomic bypass grafts
2 Vascular trauma
22 Venous surgery
Index  389

325
339
357
37


viii

Detailed contents

Contributors  xiv
Symbols and abbreviations  xv
 Arterial and venous disease
Arterial disease: atherosclerosis  2
Thromboembolic arterial disease  5
Aneurysmal disease  6
Large vessel arteritis  9
Other arterial disorders  
Venous disease: introduction  3
Varicose veins  5
Chronic venous insufficiency  6
Thromboembolic venous disease  7
Uncommon venous disorders  9



2 Arterial history and examination
History  22
Examination  26
Differential diagnosis on examination  30

2

3 Venous history and examination
History  32
Examination  36

3

4 Investigation of arterial and venous disease

Overview to investigating arterial and venous disease  40
The non-invasive vascular laboratory  4
Radiological investigations  45
Blood tests  47
Reference  47

39

5 Non-operative treatment: arterial and venous disease
Arterial disease  50
Venous disease  53
References  54

49


DETAILED CONTENTS

SYMBOLS AND ABBREVIATIONS

6 Management of complex leg ulcers
Leg ulcers in the diabetic patient  56
Ulceration associated with mixed arterial and venous
disease of the leg  60

55

7 Perioperative management of ischaemic heart disease
63
Coronary risk of peripheral vascular surgery  64

Pathophysiology of perioperative myocardial infarction  65
Preoperative assessment  66
Clinical factors  67
References  85
8 Anaesthesia for vascular surgery
87
General principles  88
Preoperative assessment  89
Management of the diabetic patient in the perioperative
period  90
Regional anaesthesia in vascular surgical patients  92
Anaesthesia for open abdominal aortic aneurysm repair  93
Anaesthesia for endovascular abdominal aortic aneurysm
repair  96
Anaesthesia for emergency abdominal aortic aneurysm
repair  97
Anaesthesia for thoraco-abdominal and suprarenal aortic
aneurysm repair  98
Anaesthesia for axillo-bifemoral bypass  99
Anaesthesia for carotid endarterectomy  00
Anaesthesia for peripheral revascularization surgery  03
Anaesthesia for amputations  04
Anaesthesia for thoracoscopic sympathectomy  05
Further reading  05
9 Managing coagulation and bleeding
07
Management of perioperative coagulation  08
Thrombolysis  5
Minimizing transfusion requirements in vascular surgery  9
Further reading  22

ix


x

SYMBOLS AND ABBREVIATIONS

DETAILED CONTENTS

0 Infection prophylaxis and treatment
Introduction to infection prophylaxis  24
Prophylactic antibiotics  25
Treatment of infection  26
Vascular surgery and prosthetics  28
Mycotic aneurysms  29
Complications of antibiotic treatment  30

23

 Graft material in bypass grafting
Types of graft material  32
Graft patency rates  36
Graft infection  37
Graft surveillance  38

3

2 Techniques of open vascular surgery
Exposure of the aorta  40

Exposure of iliac arteries  44
Exposure of the common femoral artery  46
Exposure of the popliteal artery  48
Exposure of calf and foot arteries  5
Exposure of the carotid artery  55
Exposure of the subclavian artery  57
Exposure of the axillary artery  59
Exposure of the brachial artery  6
Techniques for vascular anastomoses  62
Techniques for haemostasis  69

39

3 Abdominal aortic surgery
73
Abdominal aortic aneurysms  74
Aorto-iliac occlusive disease  78
Surgery for aorto-iliac aneurysmal and occlusive disease  79
Aortic stent graft (endovascular aneurysm repair)  8
Elective tube graft for aortic aneurysms  85
Aorto-iliac bypass graft  89
Open aortic surgery for ruptured aortic aneurysms  94
Endovascular aneurysm repair for ruptured aortic
aneurysms  97
Complex endovascular solutions  98


DETAILED CONTENTS

SYMBOLS AND ABBREVIATIONS

Aorto-bifemoral bypass graft  200
Open surgery for suprarenal aortic aneurysms  204
Open repair of suprarenal aortic aneurysms with
re-implantation of visceral arteries  205
Ilio-femoral bypass graft  209
Iliac endarterectomy  2
Treatment of aorto-enteric fistula  22
References  26
4 Thoracic aortic surgery
Thoracic aortic aneurysms  28
Thoracic aortic dissection  222

27

5 Infrainguinal revascularization
227
Infrainguinal revascularization for chronic ischaemia  228
Common femoral endarterectomy  233
Femoro-popliteal bypass graft above knee  236
Femoro-popliteal bypass graft below knee  240
Femoro-distal bypass graft: introduction  24
Femoro-distal bypass graft using vein  242
Femoro-distal sequential bypass graft using PTFE and vein  246
Composite femoro-distal bypass graft using PTFE and vein  248
Femoro-distal bypass graft using PTFE and a vein cuff   250
Popliteal aneurysm  252
Posterior approach for popliteal aneurysm bypass  253
Medial approach for popliteal aneurysm bypass  255
Femoral embolectomy  258

Popliteal embolectomy  262
Fasciotomy  263
Fasciotomy for compartment decompression  264
Release of popliteal entrapment  266
Infrainguinal angioplasty/stent insertion  268
Iliac angioplasty and stent insertion  270
6 Lower limb amputations
Overview of lower limb amputations  272
Above-knee amputation  274
Below-knee amputation  277

27

xi


xii

SYMBOLS AND ABBREVIATIONS

DETAILED CONTENTS

Through-knee amputation  280
Transmetatarsal amputation  282
Toe amputation  285
7 Vascular surgery of head and arm
Carotid endarterectomy  290
Disease of subclavian artery origin  299
Transposition of subclavian artery  300
Carotid–subclavian bypass graft  302

Temporal artery biopsy  305
Thoracic outlet syndrome  306
Endoscopic transthoracic sympathectomy  30
References  3

289

8 Surgical revascularization of kidneys
33
Overview to surgical revascularization of kidneys  34
Endovascular treatment of renal artery stenosis  35
Surgical options for revascularization  36
Transaortic endarterectomy  37
Aorto-renal graft  39
Spleno-renal bypass graft for left renal artery stenosis  32
Hepato-right renal bypass graft  323
Ilio-renal bypass graft  324
Reference  324
9 Revascularization of the gut
325
Overview to the revascularization of the gut  326
Chronic mesenteric ischaemia  328
Endovascular management of chronic mesenteric
ischaemia  329
Bypass graft to coeliac axis or superior mesenteric artery for
atherosclerotic disease  330
‘Open’ release of coeliac axis compression  332
Acute mesenteric ischaemia  333
Mesenteric embolectomy  335
Bypass graft for acute thrombosis of superior mesenteric

artery  336
Visceral aneurysms  337


DETAILED CONTENTS

SYMBOLS AND ABBREVIATIONS

20 Extra-anatomic bypass grafts
Overview of extra-anatomic bypass grafts  340
Axillo-femoral bypass graft  34
Axillo-axillary bypass graft  345
Femoro-femoral cross-over bypass  347
Obturator artery bypass graft  350
Arteriovenous fistula formation for dialysis  354

339

2 Vascular trauma
Limb trauma  358
Abdominal vascular trauma  363
Vascular trauma in the neck  367

357

22 Venous surgery
Varicose vein surgery  372
Endovenous surgery  373
Open surgery for varicose veins  377
Flush ligation of sapheno-femoral junction  380

Ligation of incompetent perforator veins  38
Avulsion of varicose veins  382
Surgery for recurrent varicose veins  384
Surgery for deep venous disease  386
Reference   388

37

Index   389

xiii


xiv

Contributors
Mr Paddy Coughlin

Dr Htun Nay Min

Consultant Vascular Surgeon
Addenbrooke’s Hospital
Cambridge, UK

Baker IDI Heart and Diabetes
Institute
Melbourne, Victoria, Australia

Chapter 5: Infrainguinal
revascularization

Chapter 8: Surgical revascularization of kidneys
Chapter 9: Revascularization of
the gut
Chapter 2: Vascular trauma
Professor Ashok Handa
Associate Professor
Nuffield Department of Surgery
University of Oxford
John Radcliffe Hospital
Oxford, UK

Chapter 5: Non-operative treatment of arterial and venous
disease

Professor Peter Karlheinz
Baker IDI Heart and Diabetes
Institute
Melbourne, Victoria, Australia

Chapter 9: Managing coagulation
and bleeding
Dr Andrew Kelion
Consultant Cardiologist
John Radcliffe Hospital
Oxford, UK

Chapter 7: Perioperative management of ischaemic heart disease

Chapter 9: Managing coagulation
and bleeding

Mr Ian Nordon
St. George's Vascular Institute
St. George's Hospital
London, UK

Chapter 3: Aortic surgery
Dr Mark Stoneham
Consultant Anaesthetist
John Radcliffe Hospital
Oxford, UK

Chapter 8: Anaesthesia for vascular
surgery
Mr John Thompson
Consultant Vascular Surgeon
Royal Devon and Exeter Hospital
Devon, UK

Chapter 7: Vascular surgery of
head and arm
Dr Flierl Ulrike
Baker IDI Heart and Diabetes
Institute
Melbourne, Victoria, Australia

Chapter 9: Managing coagulation
and bleeding


xv

Symbols and
abbreviations
7approximately
βbeta
°degree
°C
degree Celsius
8
equal to
≥
equal to or greater than
≤
equal to or less than
♀female
>
greater than
iincreased
l
leads to
<
less than
♂male
%
per cent
+plus
±
plus or minus
£
pound sterling

°primary
®

registered trademark
2°secondary
AAA
abdominal aortic aneurysm
ABPI
ankle–brachial pressure index
ACE
angiotensin-converting enzyme
A & E
accident and emergency
AF
atrial fibrillation
ANH
acute normovolaemic haemodilution
APanteroposterior
APTT
activated partial thromboplastin time
ASIS
anterior superior iliac spine
AT
anterior tibial or antithrombin
A-TOS
arterial thoracic outlet syndrome
AVarteriovenous
bd
bis in die (twice daily)
B-EVAR

branched endovascular aneurysm repair
BMI
body mass index
BMS
bare-metal stent


xvi

SYMBOLS AND ABBREVIATIONS

BP
blood pressure
bpm
beat per minute
CABG
coronary artery bypass graft
CCA
common carotid artery
CCF
congestive cardiac failure
CCT
cardiovascular computerized tomography
CEA
carotid endarterectomy
CEAP
Clinical, Etiological, Anatomical, and Pathophysiological
CFA
common femoral artery
CI

confidence interval
CIA
common iliac artery
cmcentimetre
CMR
cardiac magnetic resonance
CNS
central nervous system
CO2
carbon dioxide
COPD
chronic obstructive pulmonary disease
CPET
cardiopulmonary exercise testing
CRP
C-reactive protein
CS
compensatory sweating
CSE
combined spinal and epidural
CSF
cerebrospinal fluid
CT
computerized tomography
CTA
computerized tomographic arteriography/angiography
CVP
central venous pressure
CXR
chest X-ray

DES
drug-eluting stent
dLdecilitre
DMSA
dimercaptosuccinic acid
DMSO
dimethyl sulfoxide
DSE
dobutamine stress echocardiography
DVT
deep venous thrombosis
ECA
external carotid artery
ECGelectrocardiogram
echoechocardiography
ED
emergency department
EEGelectroencephalogram
EIA
external iliac artery
ELISA
enzyme-linked immunosorbent assay
EMGelectromyography
EPOerythropoietin


SYMBOLS AND ABBREVIATIONS

ePTFE
expanded polytetrafluoroethylene

ESR
erythrocyte sedimentation rate
ETCO2
end-tidal carbon dioxide
ETS
endoscopic transthoracic sympathectomy
ETT
endotracheal tube
EU
European Union
EVAR
endovascular aneurysm repair
FBC
full blood count
FDP
fibrin degradation product
F-EVAR
fenestrated endovascular aneurysm repair
FFP
fresh frozen plasma
FrFrench
ggram
Ggauge
GA
general anaesthesia
GCS
Glasgow coma score
GFR
glomerular filtration rate
GIgastrointestinal

GSV
greater saphenous vein
GTN
glyceryl trinitrate
hhour
Hbhaemoglobin
HbAc
glycosylated haemoglobin
HDL
high-density lipoprotein
HDL-C
high-density lipoprotein cholesterol
HDU
high-dependency unit
HIPA
heparin-induced platelet activation
HIT
heparin-induced thrombocytopenia
HIV
human immunodeficiency virus
Hzhertz
ICA
internal carotid artery
ICU
intensive care unit
IFU
instructions for use
II
image intensifier
IIA

internal iliac artery
IMA
inferior mesenteric artery
ininch
INR
international normalized ratio
IPPV
intermittent positive pressure ventilation
IU
international unit

xvii


xviii

SYMBOLS AND ABBREVIATIONS

IVintravenous
IVC
inferior vena cava
IVDU
intravenous drug use
IVI
intravenous infusion
JVP
jugular venous pressure
kgkilogram
kph
kilometre per hour

Llitre
LA
local anaesthetic
LDL
low-density lipoprotein
LDL-C
low-density lipoprotein cholesterol
LMA
laryngeal mask airway
LMWH
low-molecular-weight heparin
LSA
left subclavian artery
LSV
lesser saphenous vein
mmetre
MAGmercaptoacetyltriglycine
MAP
mean arterial pressure
MEP
motor evoked potential
mEq
milli equivalent
MET
metabolic equivalent
mgmilligram
MI
myocardial infarction
micromolmicromole
minminute

mLmillilitre
mmHg
millimetre of mercury
mmolmillimole
mph
mile per hour
MPS
myocardial perfusion scintigraphy
MRA
magnetic resonance arteriography
MRSAmethicillin-resistant Staphylococcus aureus
MRV
magnetic resonance venography
ngnanogram
NGnasogastric
NHS
National Health Service
NICE
National Institute for Health and Care Excellence
NIHR
National Institute for Health Research
NS
not significant
N-TOS
neurological thoracic outlet syndrome


SYMBOLS AND ABBREVIATIONS

O2oxygen

OCP
oral contraceptive pill
od
omni die (once daily)
OPCS
Office of Population Censuses and Surveys (code)
OR
odds ratio
Pprobability
PAposteroanterior
PABD
preoperative autologous blood donation
PACU
post-anaesthesia care unit
PAD
peripheral arterial disease
PAOD
peripheral arterial occlusive disease
PCA
patient-controlled analgesia
PCI
percutaneous coronary intervention
PE
pulmonary embolus/embolism
PET
positron emission tomography
PF4
platelet factor 4
PICC
peripherally introduced central catheter

PO
per os (orally, by mouth)
POBA
plain old balloon angioplasty
PSV
peak systolic velocity
PT
posterior tibial or prothrombin time
PTFEpolytetrafluoroethylene
PTT
partial thromboplastin time
qds
quater die sumendus (four times daily)
RCC
red cell concentrate
RCT
randomized controlled trial
RFA
radiofrequency ablation
rFVIIa
recombinant activated factor VII
rpm
revolution per minute
rtPA
recombinant tissue plasminogen activator
ssecond
SCsubcutaneous
SFA
superficial femoral artery
SFJ

sapheno-femoral junction
SHOT
Serious Hazards of Transfusion
SMA
superior mesenteric artery
SPECT
single-photon emission computerized tomography
SPJ
sapheno-popliteal junction
SpO2
oxygen saturation measured by pulse oximetry
SRA
serotonin release assay

xix


xx

SYMBOLS AND ABBREVIATIONS

STD
sodium tetradecylsulfate
SVC
superior vena cava
SVR
systemic vascular resistance
TAA
thoracic aortic aneurysm
TAAA

thoraco-abdominal aortic aneurysm
TAD
thoracic aortic dissection
TAP
transversus abdominis plane
tds
ter die sumendum (three times daily)
TEGthromboelastography
TENS
transcutaneous electrical nerve stimulation
TEVAR
thoracic endovascular aneurysm repair
TFA
transfemoral angiography
TIA
transient ischaemic attack
TKA
through-knee amputation
TOE
transoesophageal echocardiography
TOS
thoracic outlet syndrome
tPA
tissue plasminogen activator
Uunit
U & E
urea and electrolytes
UFH
unfractionated heparin
UK

United Kingdom
USA
United States of America
VKA
vitamin K antagonist
vsversus
vWF
von Willebrand factor
Wwatt
WCC
white cell count
yyear


Chapter 

Arterial and venous
disease
Arterial disease: atherosclerosis  2
Thromboembolic arterial disease  5
Aneurysmal disease  6
Large vessel arteritis  9
Other arterial disorders  
Venous disease: introduction  3
Varicose veins  5
Chronic venous insufficiency  6
Thromboembolic venous disease  7
Uncommon venous disorders  9

1

2

Chapter    Arterial

and venous disease

Arterial disease: atherosclerosis
Atherosclerosis describes the characteristic plaque or atheroma that builds
up under the arterial endothelium over time. Atherosclerosis is generally
asymptomatic, until it causes significant narrowing of an artery (>70%) or
ruptures into the lumen, generating thrombus and/or thromboemboli. It
accounts for 40% of deaths in the United Kingdom (UK).

Pathological stages
• Subintimal fatty streak.
• Inflammatory process in the media.
• Build-up of fatty macrophages (foam cells).
•Progressive narrowing of arteries.
•Plaque rupture or ulceration.
• Thrombosis with occlusion or thromboembolism (see Fig. .).

Risk factors
Progression of atherosclerosis and tendency for complications are strongly
influenced by:
•smoking;
•hypertension;
• renal disease;
•diabetes;

•hypercholesterolaemia;
• family history.

Characteristics of atherosclerosis
• Systemic disease.
•Predilection for:
• coronary arteries;
• carotid arteries;
• lower limb arteries;
• visceral/renal arteries.
• Disease progression affected by risk factor control.

Size of the problem
•Heart disease and ischaemic stroke constitute the leading causes of
death in the developed countries of the world and cause nearly a third
of all deaths annually in North America and Europe.
• The annual number of myocardial infarctions (MIs) in the United States
of America (USA) and the European Union (EU) is 2. million, and the
number of ischaemic strokes is .75 million.
• A quarter of men and one-fifth of women will suffer a stroke between
the ages of 45 and 85y.
•Peripheral vascular disease is clinically manifest as intermittent
claudication in almost 7% of the population aged 50–75y.
• Different manifestations of atherosclerotic disease commonly coexist in
the same patient (see Fig. .2).


Arterial disease: atherosclerosis

Endothelium

Thrombus

Ruptured plaque

Fig. .  Atheromatous plaque in artery.

Prevalence of vascular disease in a population 62 years of age and over

Coronary artery
disease

21%
9%
5%
8%

Peripheral
vascular disease

3%

8%
9%

Cerebrovascular
disease

Fig. .2  Coexistence of coronary, cerebral, and peripheral vascular disease.

Coronary artery disease
Coronary atherosclerosis may present with angina or MI, but significant
cardiac ischaemia is sometimes asymptomatic. Suspect coronary disease in
patients presenting with carotid or peripheral arterial atherosclerotic disease. This is important in planning intervention but also forms the premise
for stringent risk factor control. Correctable coronary artery disease may
be a treatment priority in patients presenting with other clinical manifestations of atherosclerosis.

Carotid artery disease
Atherosclerosis of the carotid arteries tends to occur at the carotid
bifurcation, which makes it amenable to carotid endarterectomy (CEA).
Haemodynamic factors of shear stress and turbulence patterns at the
bifurcation may be implicated in pathogenesis. The majority of symptomatic disease is related to thromboembolic events 2° to plaque ulceration,
platelet aggregation, and thrombosis. Symptoms of transient ischaemia or
stroke may also result from hypoperfusion caused by significant narrowing,
particularly in the context of hypotension, labile blood pressure (BP), or
contralateral carotid and/or vertebral occlusion.

3


4

Chapter    Arterial

and venous disease

Peripheral arterial occlusive disease
Atherosclerotic disease particularly affects the aorto-iliac arteries, femoral
arteries, and popliteal and distal vessels. The disease is rarely isolated to one
segment and is also usually bilateral. Significant stenosis may present with

claudication. Claudication is most common in the calf muscles, with stenosis
at any level; thigh or buttock claudication results from aorto-iliac disease.
Claudication may remain stable (7/3), improve (7/3), or progress with
symptoms coming after shorter distances (7/3).
Extreme progression of disease will result in threatened limb viability or
critical ischaemia in <5% of claudicants. This is heralded clinically by the
onset of rest pain in the forefoot or tissue loss, presenting as ulceration or
necrosis (gangrene) in the extremity. Critical ischaemia represents advanced
atherosclerotic disease and signifies multiple-level disease. Revascularization
is required to maintain limb viability.

Renovascular disease Significant stenosis of the renal arteries can

cause hypertension and renal failure. As with coronary artery disease, this
may require treatment before any other vascular intervention.

Visceral artery disease  Although frequently affected by atherosclerosis, visceral artery ischaemia is rarely symptomatic because of the rich
arterial collateral supply around the gut. Mesenteric ischaemia can result
from coexistent coeliac axis and superior mesenteric artery (SMA) disease.