Vascular surgery

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Vascular surgery

  1. 1. European Manual of Medicine Vascular Surgery C. D. Liapis Chief Editor K. Balzer, F. Benedetti-Valentini, J. Fernandes e Fernandes Editors
  2. 2. Editors C. D. Liapis, K. Balzer, F. Benedetti-Valentini, J. Fernandes e FernandesVascular SurgeryWith 385 Figures and 58 Tables123
  3. 3. Series Editors Volume EditorsWolfgang Arnold, MD Christos D. Liapis, MD, FACS, FRCSHNO und Poliklinik Department of Vascular SurgeryKlinikum rechts der Isar Athens University Medical SchoolMünchen Attikon University HospitalGermany Athens GreeceUwe Ganzer, MDHNO und Poliklinik Klaus Balzer, MDHeinrich-Heine-Universität Division of Vascular SurgeryDüsseldorf Evangelisches KrankenhausGermany Mülheim Germany Fabrizio Benedetti-Valentini, MD Department of Vascular Surgery University of Rome „La Sapienza“ Rome Italy José Fernandes e Fernandes, MD, PhD Chief of Service Department of Vascular Surgery Hospital Santa Maria and Faculty of Medicine Director Instituto Cardiovascular de Lisboa Lisbon PortugalISBN-10 3-540-30955-1Springer Berlin Heidelberg NewYorkISBN-13 978-3-540-30955-0Springer Berlin Heidelberg NewYorkLibrary of Congress Control Number: 2006928312 The use of general descriptive names, registered names, trademarks,This work is subject to copyright. All rights are reserved, whether etc. in this publication does not imply, even in the absence of a spe-the whole or part of the material is concerned, specifically the rights cific statement, that such names are exempt from the relevant pro-of translation, reprinting, reuse of illustrations, recitation, broad- tective laws and regulations and therefore free for general use.casting, reproduction on microfilms or in any other way, and stor- Product liability: The publishers cannot guarantee the accuracy ofage in data banks. Duplication of this publication or parts thereof is any information about dosage and application contained in thispermitted only under the provisions of the German Copyright Law book. In every individual case the user must check such informationof September 9, 1965, in its current version, and permission for use by consulting the relevant literature.must always be obtained from Springer-Verlag. Violations are liablefor prosecution under the German Copyright Law. Editor: Gabriele M. Schröder, Heidelberg, Germany Desk Editor: Waltraud Leuchtenberger, Heidelberg, GermanySpringer is a part of Springer Science + Business Media Production: LE-TeX Jelonek, Schmidt & Vöckler GbR,springer.com Leipzig, Germany© Springer-Verlag Berlin Heidelberg 2007 Cover Design: Frido Steinen-Broo, eStudio Calamar, Spain Printed on acid-free paper 24/3100Wa 5 4 3 2 1 0
  4. 4. VAcknowledgementsWhen the invitation came from Springer-Verlag to produce this first Europeanmanual of vascular surgery, it was accepted enthusiastically by the editors, al-beit with some trepidation concerning the demands of such a venture. Thisconcern was due to the diverse nature of the vascular system, which coversevery part of the human body; therefore, diseases of the vascular system affectall organs and all parts of the human anatomy and in order to provide a thor-ough perspective on the discipline of vascular surgery, the manual would haveto cover the full spectrum of vascular diseases. However, the pressing need to produce a long-overdue European manu-al on vascular surgery was the driving force that brought together several ofthe finest minds in Europe, who so generously accepted the task of impartingtheir expert knowledge by contributing chapters in their own specific areas.The diversity of the discipline, coupled with the differences in managementof vascular diseases by authors originating from different European countries,required the work to be carefully formatted to render it an effective referencebook, based on recommended European standards for professionals and train-ees with a common goal: optimum care of the vascular patient. The editors are deeply grateful to the distinguished authors and all theirassociates involved in this compilation. Apart from these tremendous contri-butions, this project would not have been possible without the enormous as-sistance of my associate Dr. Yannis Kakisis and the invaluable cooperation ofMs. Gabriele Schroeder and Ms. Waltraud Leuchtenberger of Springer-Verlag,Patrick Waltemate of LE-TeX and my administrative assistant Ms. VivienneRose. We hope the readership will benefit from this first European Manual ofMedicine: Vascular Surgery. The editors Christos D. Liapis Klaus Balzer Fabrizio Benedetti-Valentini José Fernandes e Fernandes
  5. 5. VIIForewordGregory D. SkalkeasProfessor Emeritus, Academician,President of the Foundation of BiomedicalResearch of the Academy of AthensVascular surgery has acquired a well-established identity throughout the Euro-pean Union, where vascular diseases are still the leading cause (40%) of deathand disability. Proper management of vascular diseases is dependent on public awarenessand appropriate training of specialists. This stands true for every medical dis-cipline. For vascular surgery it has an additional aspect because, besides therequired above-average standard of technical dexterity, the vascular surgeonshould also be well versed in a variety of subjects such as molecular biology, inthe use of ultrasound and – with the introduction of endovascular techniques– a skilful operator of guidewires and laparoscopic instruments. All the accu-mulated know-how and skills required for proper management of the vascularpatient demand a rapid change in the training of vascular surgeons and an in-depth knowledge of the various manifestations of vascular diseases. The information necessary for the above is disseminated through books,journals and the internet. Most of the time, however, articles in journals reflectthe experience and enthusiasm of the authors on the subject but not the levelof knowledge of the medical community as a whole. Electronic information isfast and reliable but always gives the reader the impression of being short-lived.Books, on the other hand, allow a reflection of what has been written and a trueinteractive role for the reader. Multi-author books have the inherited handicap of not conveying a specificmessage by virtue of the diversity of thought; however, when the authors hap-pen to be experts in their field and to represent most of the countries within theEuropean Continent that is striving to prove its successful function as a union,then such a collaboration can indeed convey a message: the level of knowledgeand the modus vivendi of vascular surgery in Europe. The editor and authors of this compilation are to be congratulated for suchan endeavour, worthy of the European spirit of unity and collaboration.
  6. 6. IXPrefaceSir Peter BellProfessor of Surgery, University of LeicesterEuropean Manual of Medicine: Vascular SurgeryVascular surgery has evolved and expanded in a spectacular fashion during thelast 50 years. During this time previously untreatable conditions have becometreatable and dealt with on a regular basis by vascular surgeons. Many of thepioneers of vascular surgery were from Europe, starting with Cid Dos Santoswho invented angiography and made the whole field of vascular surgery pos-sible. Jean Kunlin in 1949 was the first surgeon to use a reversed vein by-passgraft successfully. In the field of aortic surgery, Lerich and Matas were pio-neers in this area and Felix Eastcott started the long and successful treatmentof carotid artery stenosis by surgery. Successive generations of Europeans havecontinued to be involved in the evolution of vascular surgery, taking it to a newphase of activity. European surgeons continue to be at the forefront of changesin vascular practice and have made it possible for the new era of laparoscopicand endovascular surgery to progress and flourish. One might ask why we need yet another textbook of vascular surgery. Thisis a perfectly reasonably question and the answer is because no book exists thatoffers comprehensive knowledge, both theoretical and practical, to every levelof vascular surgeon. Buying books is expensive and it is therefore importantthat such books are of use to all of those who may wish to read them. The aimof this book is to be as useful to the vascular trainee as to the established vas-cular consultant. To this end the editors have enlisted and given a clear briefto leading practitioners in the field. All of the topics that one would normallyexpect to see in such a book are included and the text is sufficiently referencedto make it authoritative. Pictures and figures are also used but not extensivelyand are not a major selling point of this volume. The theoretical and practi-cal aspects of open surgery, endovascular procedures and laparoscopic surgeryare all covered in detail and venous disease and lymphatic problems are notignored. One question that might be asked is: why are all the contributing surgeonsfrom Europe and none from other countries or continents? This is intentionaland not xenophobic, but an attempt to show that the necessary expertise tocover all aspects of the practice of vascular surgery exists in the expanded Eu-ropean community. It is also to acknowledge the fact that vascular proceduresand practice are not necessarily the same the world over. The approach to someproblems is different in Europe than it is in other continents and these differ-ences are reflected in this book. I am sure that those who buy and read thisbook will not be disappointed in its content or style. It will be extremely usefulto all readers and be a signpost to the future of vascular surgery.
  7. 7. XIIntroductionChristos D. Liapis, John D. KakisisVascular diseases are the most frequent cause of death and disability of Eu-ropeans. The aim of the present book, European Manual of Medicine: Vascu-lar Surgery, is to give an indication of European standards for the diagnosisand therapy of vascular diseases. It is designed with the same format as otherbooks in the series European Manuals of Medicine and focuses on the descrip-tion of each clinical entity (definition, epidemiology, aetiology, symptoms andcomplications) and on the recommended European standard diagnostic andtherapeutic steps. In contrast to other textbooks, most of the information ispresented in bulleted listings instead of lengthy paragraphs. This is done in thehope of enabling the reader to retrieve information easily and quickly. The first chapters of this book refer to the pathogenesis of vascular diseases,including the development of atherosclerosis and the effect of dyslipidaemia,clotting disorders and emerging biochemical risk factors. Subsequent chapterspresent the noninvasive and invasive means of diagnosis, including latest de-velopments such as computer-guided diagnosis of vascular diseases. The pre-operative evaluation and optimization as well as the peri-operative care of thevascular patient are also discussed. The book includes a review of the history ofvascular surgery in Europe and a chapter on the training of vascular surgeonsfor endovascular procedures in order to highlight the continuity and the prog-ress of vascular surgery over the past century and the future perspectives. Thechapters of the book cover the entire range of arterial, venous and lymphaticdisorders with an emphasis on all recent developments including endovascularand laparoscopic surgery. The text is comprehensive since the book is intendednot only for vascular specialists but also for students, residents in vascular sur-gery and other interested physicians. The chapters have been written mainly by national representatives on thenewly established Section of Vascular Surgery of the European Union of Medi-cal Specialists (UEMS), thus drawing upon the collective experience of vascu-lar surgeons/specialists from the various European countries. The authors areexperts in their field, providing the reader with a professional opinion reflect-ing what is generally considered to be the state-of-the-art in each area. We hope that the readers, especially the hard working trainees in vascularsurgery to whom this book is dedicated, will find it useful.
  8. 8. XIII ContentsVascular Surgery and the Vascular Patient 1.2.2.2 Initiation of Atherosclerosis and Role of Endothelial1.1 The History of Vascular Surgery Dysfunction . . . . . . . . . . . . . . . . . . . . . . 23 in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2.2.3 Evolution of the Atherosclerotic1.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 3 Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . 261.1.2 The Origin and the Foundations 1.2.3 Contributive Factors of European Vascular Surgery . . . . . . . 3 to Endothelial Dysfunction1.1.3 Europe, Cradle of the World’s and Plaque Formation . . . . . . . . . . . . . 28 Vascular Surgery . . . . . . . . . . . . . . . . . . . 7 1.2.3.1 Miscellaneous Factor . . . . . . . . . . . . . . 281.1.3.1 The Nursery of Vascular Surgery 1.2.3.2 The Oxidized LDL Hypothesis . . . . . . 28 in Europe in the 1930s was 1.2.4 Plaque Instability the René Leriche School in and Complicated Plaques . . . . . . . . . . 30 Strasburg, France . . . . . . . . . . . . . . . . . . 8 1.2.5 Classification of Atherosclerotic1.1.3.2 Reference to European Surgeons Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 who Through their Pioneering 1.2.6 Assessment and Evaluation Work Developed Vascular of the Risk of an Atherosclerotic Surgery in their Continent with Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 International Influence . . . . . . . . . . . . 10 1.2.7 General Therapeutic Measures . . . . . 311.1.3.3 Medical and Interventional 1.2.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 32 Vascular Contributions to References . . . . . . . . . . . . . . . . . . . . . . . . 32 the Development of Vascular Surgery in Europe and Worldwide . . 12 1.3 Lipids and Peripheral Arterial1.1.4 European Vascular Surgical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 and Angiological Societies and 1.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 35 Congresses . . . . . . . . . . . . . . . . . . . . . . . 14 1.3.2 Effect of Lipid Lowering on PAD . . . 351.1.5 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.3.2.1 Prevention of PAD . . . . . . . . . . . . . . . . 35 Acknowledgements . . . . . . . . . . . . . . . 19 1.3.2.2 Improvement of Symptoms References . . . . . . . . . . . . . . . . . . . . . . . . 20 Associated with PAD . . . . . . . . . . . . . 35 1.3.2.3 Reduction of the Risk of1.2 Development of Atherosclerosis Vascular Events Associated with for the Vascular Surgeon . . . . . . . . . . . 23 PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . 23 1.3.3 Peripheral Vascular Surgery and1.2.2 Physiopathology of Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Atherosclerosis . . . . . . . . . . . . . . . . . . . 23 1.3.4 Additional Potential Actions1.2.2.1 Normal Blood Vessel of Lipid-lowering Drugs Morphology . . . . . . . . . . . . . . . . . . . . . . 23 that may Benefit PAD Patients . . . . . 37 1.3.5 Are all Statins the Same? . . . . . . . . . . . 37
  9. 9. XIV Contents 1.3.6 Concluding Comments . . . . . . . . . . . . 37 1.6 Invasive Diagnosis of Vascular References . . . . . . . . . . . . . . . . . . . . . . . . 38 Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 65 1.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 65 1.4 Clotting Disorders: What Should 1.6.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 the Vascular Surgeon Know 1.6.3 Arteriography . . . . . . . . . . . . . . . . . . . . . 68 About Hypercoagulation States 1.6.3.1 Techniques . . . . . . . . . . . . . . . . . . . . . . . 68 in Venous Diseases? . . . . . . . . . . . . . . . 41 1.6.3.2 Pre-procedure Evaluation 1.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 41 and Preparation . . . . . . . . . . . . . . . . . . . 69 1.4.2 Venous Thrombosis . . . . . . . . . . . . . . . 41 1.6.3.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . 69 1.4.2.1 Risk Factors . . . . . . . . . . . . . . . . . . . . . . 41 1.6.3.4 Post-procedure Care . . . . . . . . . . . . . . . 70 1.4.3 What Should a Surgeon do when 1.6.3.5 Complications . . . . . . . . . . . . . . . . . . . . 70 Faced with Hypercoagulation? . . . . . 45 1.6.3.6 Direct Toxicity . . . . . . . . . . . . . . . . . . . 71 1.4.3.1 Should a Search for 1.6.4 Phlebography . . . . . . . . . . . . . . . . . . . . . 72 Thrombophilia be Undertaken? . . . . 45 1.6.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . 72 1.4.3.2 How Should the Search 1.6.4.2 Techniques . . . . . . . . . . . . . . . . . . . . . . . 72 be Done? . . . . . . . . . . . . . . . . . . . . . . . . . 45 References . . . . . . . . . . . . . . . . . . . . . . . . 74 1.4.3.3 Diagnosing Thrombotic Disease in Patients with Thrombophilia . . . . . 46 1.7 Computer-Aided Diagnosis 1.4.3.4 Treating Thromboembolic of Vascular Disease . . . . . . . . . . . . . . . . 77 Disease in Patients 1.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . 77 with Thrombophilia . . . . . . . . . . . . . . 46 1.7.2 Computer-Aided Diagnosis 1.4.3.5 Specific Considerations in Vascular Imaging . . . . . . . . . . . . . . . 77 in Treating Thromboembolic 1.7.2.1 Image Pre-processing . . . . . . . . . . . . . . 78 Disease Related to Thrombophilia . . 46 1.7.2.2 Definition of Regions of Interest 1.4.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . 47 – Automatic Segmentation . . . . . . . . . 78 References . . . . . . . . . . . . . . . . . . . . . . . 47 1.7.2.3 Extraction and Selection of Characteristic Features . . . . . . . . . 78 1.5 Noninvasive Diagnosis 1.7.2.4 Classification . . . . . . . . . . . . . . . . . . . . . 80 of Vascular Diseases . . . . . . . . . . . . . . . 51 1.7.2.5 ANALYSIS: a Modular Software 1.5.1 Peripheral Arterial Disease . . . . . . . . . 51 System to Support Diagnosis 1.5.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 51 of Vascular Disease . . . . . . . . . . . . . . . . 81 1.5.1.2 Physical Examination . . . . . . . . . . . . . . 51 1.7.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 82 1.5.1.3 Basic Haematological References . . . . . . . . . . . . . . . . . . . . . . . 82 and Biochemical Tests . . . . . . . . . . . . . 51 1.5.1.4 Special Investigations, Other 1.8 Preoperative Evaluation Than Imaging . . . . . . . . . . . . . . . . . . . . . 51 of a Vascular Patient . . . . . . . . . . . . . . . 85 1.5.1.5 Imaging Techniques . . . . . . . . . . . . . . . 54 1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 85 1.5.1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 55 1.8.2 Systemic Evaluation . . . . . . . . . . . . . . . 85 1.5.2 Disease of Arteries Supplying 1.8.2.1 Cardiovascular System . . . . . . . . . . . . . 85 the Brain . . . . . . . . . . . . . . . . . . . . . . . . . 56 1.8.2.2 Respiratory System . . . . . . . . . . . . . . . . 86 1.5.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 56 1.8.2.3 Renal System . . . . . . . . . . . . . . . . . . . . . 88 1.5.2.2 Imaging Techniques . . . . . . . . . . . . . . . 56 1.8.3 Evaluation of Specific Vascular 1.5.2.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 59 Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 1.5.3 Diseases of the Venous 1.8.3.1 Aneurysmal Disease: Circulation . . . . . . . . . . . . . . . . . . . . . . . 59 Abdominal Aortic Aneurysm . . . . . . 89 1.5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 59 1.8.3.3 Peripheral Vascular Disease: 1.5.3.2 Chronic Venous Insufficiency . . . . . . 59 Chronic Lower Limb Ischaemia . . . . 89 1.5.3.3 Deep Vein Thrombosis . . . . . . . . . . . . 61 1.8.3.4 Peripheral Vascular Disease: 1.5.3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 61 Acute Limb Ischaemia . . . . . . . . . . . . . 90 References . . . . . . . . . . . . . . . . . . . . . . . . 62 1.8.3.5 Carotid Disease . . . . . . . . . . . . . . . . . . . 91
  10. 10. Contents XV1.8.3.6 Venous Disease . . . . . . . . . . . . . . . . . . . 92 1.10 Training of the Vascular References . . . . . . . . . . . . . . . . . . . . . . . . 93 Surgeonfor Endovascular Procedures . . . . . . . . . . . . . . . . . . . . . 1071.9 Peri-operative Care References . . . . . . . . . . . . . . . . . . . . . . 110 of the Vascular Patient . . . . . . . . . . . . . 951.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 95 1.11 Peripheral Arterial Disease and1.9.2 Preoperative Planning . . . . . . . . . . . . . 95 Emerging Biochemical Vascular1.9.3 Effects of Anaesthesia . . . . . . . . . . . . . . 95 Risk Factors . . . . . . . . . . . . . . . . . . . . 1111.9.4 Peri-operative Monitoring . . . . . . . . . 96 1.11.1 Introduction . . . . . . . . . . . . . . . . . . . . 1111.9.4.1 Monitoring for Cardiac 1.11.2 Homocysteine (Hcy) . . . . . . . . . . . . 111 Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . 96 1.11.3 C-reactive Protein (CRP) . . . . . . . . 1111.9.4.2 Peri-operative Temperature 1.11.4 Lipoprotein (a) [Lp(a)] . . . . . . . . . . 112 Control . . . . . . . . . . . . . . . . . . . . . . . . . . 96 1.11.5 Fibrinogen . . . . . . . . . . . . . . . . . . . . . . 1121.9.4.3 Level of Hypnotic Depth . . . . . . . . . . . 97 1.11.6 Endothelium . . . . . . . . . . . . . . . . . . . . 1131.9.5 Prevention of Cardiac Ischaemia . . . 97 1.11.7 PAD and Other Potentially1.9.5.1 Preoperative Revascularization . . . . . 97 Relevant Emerging Risk Factors . . 1131.9.5.2 Good Peri-operative 1.11.7.1 Creatinine . . . . . . . . . . . . . . . . . . . . . . 113 Haemodynamic Control . . . . . . . . . . . 97 1.11.7.2 Urate . . . . . . . . . . . . . . . . . . . . . . . . . . 1131.9.5.3 Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . 97 1.11.7.3 Microalbuminuria . . . . . . . . . . . . . . 1141.9.5.4 Adrenergic Tone . . . . . . . . . . . . . . . . . . 97 1.11.7.4 Insulin Resistance and Metabolic1.9.5.5 Postoperative Ischaemia Syndrome . . . . . . . . . . . . . . . . . . . . . . 114 Prevention . . . . . . . . . . . . . . . . . . . . . . . 98 1.11.7.5 Platelets, Fibrinolysis1.9.6 Aneurysm Surgery . . . . . . . . . . . . . . . . 98 and D-Dimers . . . . . . . . . . . . . . . . . . 1141.9.6.1 Effects of Clamping and 1.11.7.6 Other Markers of Inflammation . . 114 Declamping . . . . . . . . . . . . . . . . . . . . . . 98 1.11.8 Conclusions . . . . . . . . . . . . . . . . . . . . 1141.9.6.2 Prevention of Spinal Cord References . . . . . . . . . . . . . . . . . . . . . 115 Ischaemia in Thoracic Aortic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 99 1.12 Quality Control in Vascular1.9.6.3 Autotransfusion During Surgery . . . . 99 Surgery . . . . . . . . . . . . . . . . . . . . . . . . 1171.9.7 Heparin . . . . . . . . . . . . . . . . . . . . . . . . . . 99 1.12.1 Introduction . . . . . . . . . . . . . . . . . . . . 1171.9.7.1 Peri-operative Heparin . . . . . . . . . . . . 99 1.12.1.1 Physical Examination . . . . . . . . . . . . 1171.9.7.2 Prophylaxis of Deep Leg Vein 1.12.1.2 Angiography . . . . . . . . . . . . . . . . . . . . 117 Thrombosis . . . . . . . . . . . . . . . . . . . . . 100 1.12.1.3 Continuous Wave (CW)1.9.8 Peri-operative Monitoring Doppler . . . . . . . . . . . . . . . . . . . . . . . . 117 after Arterial Reconstructions . . . . 100 1.12.1.4 Duplex and Colour Duplex Scan . . 1181.9.9 Prophylactic Antibiotic 1.12.1.5 Intravascular Ultrasonography Administration . . . . . . . . . . . . . . . . . 100 (IVUS) . . . . . . . . . . . . . . . . . . . . . . . . . 1181.9.10 Postoperative Pain Treatment . . . . 100 1.12.1.6 Angioscopy . . . . . . . . . . . . . . . . . . . . . 1181.9.11 Pulmonary Complications, 1.12.1.7 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 119 Prophylaxis and Treatment . . . . . . . 100 1.12.2 Arteries of the Abdomen . . . . . . . . 1191.9.12 Peri-operative Care 1.12.2.1 Abdominal Aorta . . . . . . . . . . . . . . . 119 and Endovascular Surgery . . . . . . . 101 1.12.2.2 Visceral Arteries . . . . . . . . . . . . . . . . 1191.9.13 Intensive Care Ward is Needed 1.12.2.3 Renal Arteries . . . . . . . . . . . . . . . . . . 120 Only for Selected Patients . . . . . . . . 101 1.12.3 Lower Extremity By-pass . . . . . . . . 1201.9.14 Pre- and Postoperative Gut 1.12.3.1 Angiography . . . . . . . . . . . . . . . . . . . . 121 Function and Nutrition . . . . . . . . . . 101 1.12.3.2 Ultrasound (CW Doppler, PW1.9.15 Discharge Planning . . . . . . . . . . . . . . 102 Doppler, Duplex, Colour Duplex) 1221.9.16 Summary . . . . . . . . . . . . . . . . . . . . . . . 103 1.12.3.3 Angioscopy . . . . . . . . . . . . . . . . . . . . . 123 References . . . . . . . . . . . . . . . . . . . . . . 103 1.12.3.4 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 124 1.12.3.5 Conclusions . . . . . . . . . . . . . . . . . . . . 124
  11. 11. XVI Contents 1.12.4 Carotid Arteries . . . . . . . . . . . . . . . . . 124 2.2.5.3 Technique of Carotid References . . . . . . . . . . . . . . . . . . . . . . 127 Endarterectomy . . . . . . . . . . . . . . . . . 146 2.2.6 Endovascular Treatment . . . . . . . . . 149 2.2.6.1 What are the Established Cerebrovascular Arteries Indications for Endovascular Procedures in Extracranial 2.1 Haemodynamic Changes Carotid Disease? . . . . . . . . . . . . . . . . 149 and Other Risk Factors References . . . . . . . . . . . . . . . . . . . . . . 150 for Complications During Carotid Procedures . . . . . . . . . . . . . . 131 2.3 Eversion Carotid 2.1.1 Cerebral Blood Flow . . . . . . . . . . . . . 131 Endarterectomy Technique . . . . . . 155 2.1.2 General Complications . . . . . . . . . . 131 2.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 155 2.1.3 Cerebral Monitoring 2.3.2 Technique . . . . . . . . . . . . . . . . . . . . . . 155 and Protection During CEA . . . . . . 132 2.3.3 Advantages . . . . . . . . . . . . . . . . . . . . . 159 2.1.4 Cerebral Embolization during 2.3.4 Disadvantages . . . . . . . . . . . . . . . . . . 159 CEA and CAS . . . . . . . . . . . . . . . . . . 133 2.3.5 Conclusion . . . . . . . . . . . . . . . . . . . . . 159 2.1.5 Adjuvant Medical Therapy . . . . . . . 133 References . . . . . . . . . . . . . . . . . . . . . . 159 2.1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . 134 References . . . . . . . . . . . . . . . . . . . . . . 134 2.4 Fibromuscular Dysplasia . . . . . . . . . 161 2.4.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 161 2.2 Extracranial Carotid Artery 2.4.1.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . 161 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 137 2.4.1.2 Physiology, Pathophysiology . . . . . 161 2.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 137 2.4.1.3 Organ-related Questions . . . . . . . . . 165 2.2.2 Pathogenesis of Brain Ischaemia . . 138 2.4.1.4 Principles of Clinical 2.2.3 Clinical Manifestations . . . . . . . . . . 140 Examination . . . . . . . . . . . . . . . . . . . . 165 2.2.3.1 Amaurosis fugax . . . . . . . . . . . . . . . . 140 2.4.1.5 Technical Diagnostic Procedures . . 165 2.2.3.2 Transient/Reversible Cerebral 2.4.1.6 Organ-specific Radiology . . . . . . . . 166 Ischaemia . . . . . . . . . . . . . . . . . . . . . . 140 2.4.2 Organ-related Diseases . . . . . . . . . . 166 2.2.3.3 Established Stroke . . . . . . . . . . . . . . . 140 2.4.2.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 166 2.2.3.4 Stroke in Evolution (“Waving 2.4.2.2 Definition . . . . . . . . . . . . . . . . . . . . . . 166 and Waning”) . . . . . . . . . . . . . . . . . . . 140 2.4.2.3 Epidemiology/Aetiology . . . . . . . . . 166 2.2.3.5 Global Cerebral Ischaemia . . . . . . . 140 2.4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 167 2.2.3.6 Asymptomatic Carotid Disease . . . 141 2.4.2.5 Complications . . . . . . . . . . . . . . . . . . 168 2.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 141 2.4.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 168 2.2.4.1 Arteriography . . . . . . . . . . . . . . . . . . . 141 2.4.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 168 2.2.4.2 Colour Flow Duplex Scan . . . . . . . 141 2.4.2.8 Differential Diagnosis . . . . . . . . . . . 169 2.2.4.3 High-resolution 2.4.2.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 169 Ultrasonography . . . . . . . . . . . . . . . . 143 2.4.2.10 Exemplary Surgical Procedures . . . 169 2.2.4.4 Measuring the Degree of Stenosis . 143 2.4.2.11 Special Remarks . . . . . . . . . . . . . . . . . 170 2.2.4.5 Transcranial Doppler References . . . . . . . . . . . . . . . . . . . . . . 170 Examination . . . . . . . . . . . . . . . . . . . 144 2.2.4.6 Other Flow-imaging Techniques . . 144 2.5 Aneurysms of the Extracranial 2.2.4.7 Indications for Arteriography . . . . 144 Carotid Arteries . . . . . . . . . . . . . . . . 173 2.2.4.8 Computerized Tomography 2.5.1 Definition and Historical and Magnetic Resonance Imaging 144 Background . . . . . . . . . . . . . . . . . . . . 173 2.2.4.9 Examination of the Retina . . . . . . . 144 2.5.2 Epidemiology/Aetiology . . . . . . . . . 173 2.2.5 Selection, Treatment and Results . . 145 2.5.2.1 Atherosclerosis Aneurysms . . . . . . 173 2.2.5.1 Medical Treatment . . . . . . . . . . . . . . 145 2.5.2.2 Previous Surgery/POS 2.2.5.2 Surgical Treatment . . . . . . . . . . . . . . 145 Endarterectomy . . . . . . . . . . . . . . . . . 174
  12. 12. Contents XVII2.5.2.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.1 Technical Failure . . . . . . . . . . . . . . . . 1932.5.2.4 Infection . . . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.2 Contrast Encephalopathy . . . . . . . . 1932.5.2.5 Dissections . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.3 Access Site Complications . . . . . . . . 1932.5.2.6 Other Possible Causes . . . . . . . . . . . 174 2.6.8.4 Hyperperfusion Syndrome2.5.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 175 (Fig. 2.6.16) . . . . . . . . . . . . . . . . . . . . . 1932.5.4 Complications . . . . . . . . . . . . . . . . . . 175 2.6.8.5 Hypotension and Bradycardia . . . 1942.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 175 2.6.8.6 Embolic Complication . . . . . . . . . . . 1942.5.5.1 Recommended European 2.6.8.7 Complications Involving Brain Standard Diagnostic Steps Protection Devices . . . . . . . . . . . . . . 195 of Investigation . . . . . . . . . . . . . . . . . 175 2.6.9 Follow-up . . . . . . . . . . . . . . . . . . . . . . 1952.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 176 2.6.10 Carotid Angioplasty and2.5.6.1 Conservative Treatment . . . . . . . . . 176 Stenting (CAS): Present and Future 1962.5.6.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 177 References . . . . . . . . . . . . . . . . . . . . . . 197 References . . . . . . . . . . . . . . . . . . . . . . 179 2.7 Carotid body tumour . . . . . . . . . . . . 2012.6 Endovascular Treatment 2.7.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 201 of Carotid Stenosis . . . . . . . . . . . . . . 181 2.7.2 Definition of the Disease . . . . . . . . . 2012.6.1 Introduction . . . . . . . . . . . . . . . . . . . . 181 2.7.3 Epidemiology/Aetiology . . . . . . . . . 2012.6.2 Indications for Surgery 2.7.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 202 – Indications for Angioplasty . . . . . 181 2.7.5 Complications . . . . . . . . . . . . . . . . . . 2022.6.3 Types of Stents . . . . . . . . . . . . . . . . . . 183 2.7.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 2032.6.4 Brain Protection Devices . . . . . . . . . 184 2.7.6.1 Recommended European2.6.4.1 Distal Occlusion Balloon Standard Diagnostic Steps (Theron’s System, PercuSurge of Investigation . . . . . . . . . . . . . . . . . 203 GuardWire® Medtronic) 2.7.6.2 Additional Useful Diagnostic (Fig. 2.6.5) . . . . . . . . . . . . . . . . . . . . . . 184 Procedures . . . . . . . . . . . . . . . . . . . . . 2052.6.4.2 Filters . . . . . . . . . . . . . . . . . . . . . . . . . . 184 2.7.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2062.6.4.3 Proximal Occlusion System . . . . . . 186 2.7.7.1 Conservative therapy . . . . . . . . . . . . 2062.6.5 Preoperative Evaluation . . . . . . . . . . 187 2.7.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 2062.6.5.1 Neurological Examination . . . . . . . 188 2.7.8 Differential Diagnosis . . . . . . . . . . . 2082.6.5.2 Special Imaging Examination . . . . 188 References . . . . . . . . . . . . . . . . . . . . . 2082.6.5.3 Duplex Ultrasound . . . . . . . . . . . . . . 1882.6.5.4 Digital Subtraction Angiography 2.8 Combined Treatment of (DSA) . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Coronary Plus Other Arterial2.6.5.5 Magnetic Resonance Pathologies: the Magnitude of Angiography (MRA) (Fig. 2.6.10) . . 189 the Polyatherosclerotic Patient . . . 2092.6.5.6 Brain Computed Tomography 2.8.1 Introduction . . . . . . . . . . . . . . . . . . . . 209 (CT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 2.8.2 The Magnitude of Multifocal2.6.6 Technique . . . . . . . . . . . . . . . . . . . . . . 190 Arterial Disease . . . . . . . . . . . . . . . . . 2092.6.6.1 Step 1: Approach to the 2.8.2.1 Material and Methods . . . . . . . . . . . 209 Common Carotid Artery Access 2.8.2.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 209 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 2.8.3 Multifocal Occlusive2.6.6.2 Step 2: Cannulation of the and Aneurysmal Arterial Disease . 211 Common Carotid Artery 2.8.4 Multifocal Carotid and (Fig. 2.6.12) . . . . . . . . . . . . . . . . . . . . . 191 Coronary Occlusive Disease . . . . . 2122.6.6.3 Step 3: Angioplasty and Stenting . . 192 2.8.4.1 Material and Methods . . . . . . . . . . . 2132.6.6.4 Step 4: Control Angiography . . . . . 193 2.8.4.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 2142.6.7 Peri-operative Monitoring . . . . . . . 193 Acknowledgements . . . . . . . . . . . . . 2142.6.8 Complications . . . . . . . . . . . . . . . . . . 193 References . . . . . . . . . . . . . . . . . . . . . . 214
  13. 13. XVIII Contents Upper Extremity Arteries 3.2.2.2 Epidemiology/Aetiology . . . . . . . . . 240 3.2.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 240 3.1 Upper Extremity Occlusive 3.2.2.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 241 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 219 3.2.3 Acrocyanosis . . . . . . . . . . . . . . . . . . . 242 3.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 219 3.2.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 242 3.1.2 Types of Upper Extremity 3.2.3.2 Epidemiology/Aetiology . . . . . . . . . 242 Occlusive Disease . . . . . . . . . . . . . . . 219 3.2.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 242 3.1.2.1 Acute and Chronic Ischaemia . . . . 219 3.2.3.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 243 3.1.2.2 Raynaud’s Phenomenon . . . . . . . . . 219 3.2.4 Livedo Reticularis . . . . . . . . . . . . . . . 243 3.1.2.3 Trophic Lesions . . . . . . . . . . . . . . . . . 220 3.2.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 243 3.1.2.4 Differential Diagnosis of Upper 3.2.4.2 Epidemiology/Aetiology . . . . . . . . . 243 Extremity Occlusive Disease . . . . . 220 3.2.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 243 3.1.3 Embolism . . . . . . . . . . . . . . . . . . . . . . 220 3.2.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 243 3.1.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 220 3.2.5 Cold Hypersensitivity . . . . . . . . . . . 243 3.1.3.2 Epidemiology/Aetiology . . . . . . . . . 220 3.2.5.1 Definition . . . . . . . . . . . . . . . . . . . . . . 243 3.1.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 220 3.2.5.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 244 3.1.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 221 3.2.5.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 244 3.1.3.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 221 3.2.6 Complex Regional Pain 3.1.4 Occlusive Arterial Disease . . . . . . . 222 Syndrome . . . . . . . . . . . . . . . . . . . . . . 245 3.1.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 222 3.2.6.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 245 3.1.4.2 Proximal Arterial Disease . . . . . . . . 222 3.2.6.2 Definition . . . . . . . . . . . . . . . . . . . . . . 245 3.1.4.3 Distal Arterial Disease . . . . . . . . . . . 226 3.2.6.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 245 3.1.5 Aneurysms . . . . . . . . . . . . . . . . . . . . . 232 3.2.6.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 245 3.1.5.1 Epidemiology/Aetiology . . . . . . . . . 232 3.2.6.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 245 3.1.5.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 232 References . . . . . . . . . . . . . . . . . . . . . . 246 3.1.5.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 232 3.1.6 Arteriovenous Fistulae . . . . . . . . . . . 232 3.3 Thoracic Outlet Syndrome . . . . . . . 247 3.1.6.1 Epidemiology/Aetiology . . . . . . . . . 232 3.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 247 3.1.6.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2 Neurogenic Thoracic Outlet 3.1.6.3 Investigations . . . . . . . . . . . . . . . . . . . 233 Compression Syndrome (N-TOCS) 247 3.1.6.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.1 Epidemiology/Aetiology . . . . . . . . . 247 3.1.7 Vascular Trauma . . . . . . . . . . . . . . . . 233 3.3.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 247 3.1.7.1 Epidemiology/Aetiology . . . . . . . . . 233 3.3.2.3 Clinical Examination . . . . . . . . . . . . 247 3.1.7.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 248 3.1.7.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 248 3.1.8 Iatrogenic Aetiologies . . . . . . . . . . . 233 3.3.3 Arterial Thoracic Outlet 3.1.9 Conclusion . . . . . . . . . . . . . . . . . . . . . 234 Compression Syndrome References . . . . . . . . . . . . . . . . . . . . . . 234 (A-TOCS) . . . . . . . . . . . . . . . . . . . . . 251 3.3.3.1 Epidemiology/Aetiology . . . . . . . . . 251 3.2 Vasospastic Disorders 3.3.3.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 251 of the Upper Extremities . . . . . . . . . 237 3.3.3.3 Investigations/Examination . . . . . . 251 3.2.1 Raynaud’s Syndrome . . . . . . . . . . . . 237 3.3.3.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 251 3.2.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 237 3.3.4 A Case Apart: Primary 3.2.1.2 Epidemiology/Aetiology . . . . . . . . . 237 Subclavian–Axillary Vein 3.2.1.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 237 Thrombosis . . . . . . . . . . . . . . . . . . . . . 254 3.2.1.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 237 3.3.4.1 Epidemiology/Aetiology . . . . . . . . . 254 3.2.1.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 239 3.3.4.2 Primary SVT . . . . . . . . . . . . . . . . . . . 254 3.2.2 Hyperhidrosis . . . . . . . . . . . . . . . . . . . 240 3.3.5 Summary . . . . . . . . . . . . . . . . . . . . . . . 256 3.2.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 240 References . . . . . . . . . . . . . . . . . . . . . . 256
  14. 14. Contents XIX3.4 Traumatic Injury of Upper 4.2.3.5 Localization . . . . . . . . . . . . . . . . . . . . 278 Extremity Arteries . . . . . . . . . . . . . . 257 4.2.3.6 Classification . . . . . . . . . . . . . . . . . . . 2783.4.1 Epidemiology . . . . . . . . . . . . . . . . . . . 257 4.2.3.7 Factors Determining Extension3.4.2 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 257 of Dissection . . . . . . . . . . . . . . . . . . . 2793.4.2.1 Penetrating Trauma . . . . . . . . . . . . . 257 4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 2823.4.2.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . 257 4.2.4.1 Stanford Type A . . . . . . . . . . . . . . . . 2823.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 257 4.2.4.2 Stanford Type B . . . . . . . . . . . . . . . . 2823.4.3.1 Recommended European 4.2.5 Complications . . . . . . . . . . . . . . . . . . 283 Standard Diagnostic Steps 4.2.5.1 Type A . . . . . . . . . . . . . . . . . . . . . . . . . 283 of Investigation . . . . . . . . . . . . . . . . . 257 4.2.5.2 Type B . . . . . . . . . . . . . . . . . . . . . . . . . 2833.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 258 4.2.6 Diagnosis/Investigation . . . . . . . . . . 2853.4.4.1 Conservative Therapy . . . . . . . . . . . 258 4.2.6.1 Recommended European3.4.4.2 Endovascular Therapy . . . . . . . . . . . 258 Standard Diagnostic Steps3.4.4.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 258 of Investigation . . . . . . . . . . . . . . . . . 2853.4.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 259 4.2.6.2 Additional Useful Diagnostic References . . . . . . . . . . . . . . . . . . . . . . 260 Procedures . . . . . . . . . . . . . . . . . . . . . 285 4.2.6.3 Clinical Judgement . . . . . . . . . . . . . . 285 4.2.7 Prognosis of Acute or SubacuteThoracic Aorta Aortic Dissection Without Treatment . . . . . . . . . . . . . . . . . . . . . . 2894.1 Thoracoabdominal Aneurysms . . . 265 4.2.8 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 2894.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 265 4.2.8.1 Treatment of Type A Aortic4.1.2 Epidemiology/Aetiology . . . . . . . . . 265 Dissection . . . . . . . . . . . . . . . . . . . . . . 2894.1.3 Investigations . . . . . . . . . . . . . . . . . . . 266 4.2.8.2 Treatment of Type B Aortic4.1.3.1 Imaging . . . . . . . . . . . . . . . . . . . . . . . . 266 Dissection . . . . . . . . . . . . . . . . . . . . . . 2904.1.3.2 Additional Investigations . . . . . . . . 266 References . . . . . . . . . . . . . . . . . . . . . . 2964.1.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 2674.1.4.1 Operative Repair . . . . . . . . . . . . . . . . 267 4.3 Trauma of the Thoracic Aorta . . . . 2994.1.4.2 Open Surgery: Operative 4.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 299 Technique . . . . . . . . . . . . . . . . . . . . . . 267 4.3.2 Epidemiology . . . . . . . . . . . . . . . . . . . 2994.1.4.3 Open Surgery: Adjuvant 4.3.2.1 Automobile-related Incidences . . . 299 Techniques . . . . . . . . . . . . . . . . . . . . . 267 4.3.2.2 Blunt Thoracic Trauma . . . . . . . . . . 2994.1.5 Endovascular Intervention . . . . . . . 269 4.3.2.3 Outcome . . . . . . . . . . . . . . . . . . . . . . . 3004.1.5.1 Visceral Hybrid Procedure . . . . . . . 269 4.3.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 3004.1.6 Outcome . . . . . . . . . . . . . . . . . . . . . . . 271 4.3.3.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . 3004.1.7 Summary and Conclusions . . . . . . . 272 4.3.3.2 Mechanism of Pathology . . . . . . . . . 301 References . . . . . . . . . . . . . . . . . . . . . . 273 4.3.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 301 4.3.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 3024.2 Aortic Dissection . . . . . . . . . . . . . . . . 277 4.3.5.1 Recommended European4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 277 Standard Diagnostic Steps4.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . 277 of Investigation . . . . . . . . . . . . . . . . . 3024.2.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 3064.2.3.1 Association with Atherosclerotic 4.3.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 306 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6.2 Endovascular Approach . . . . . . . . . 3094.2.3.2 Association with Genetic References . . . . . . . . . . . . . . . . . . . . . . 312 Disease/Congenital Malformations . . . . . . . . . . . . . . . . . . 2774.2.3.3 Association with Trauma . . . . . . . . 2774.2.3.4 Other Associations . . . . . . . . . . . . . . 277
  15. 15. XX Contents Abdominal Aorta and Iliac Arteries 5.3.4.2 Infection . . . . . . . . . . . . . . . . . . . . . . . 333 5.3.4.3 Autoimmune Disease . . . . . . . . . . . . 333 5.1 Abdominal Aortic Aneurysm 5.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 333 (AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 317 5.3.5.1 Literature . . . . . . . . . . . . . . . . . . . . . . . 334 5.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 317 5.3.5.2 Rupture . . . . . . . . . . . . . . . . . . . . . . . . 334 5.1.2 Definition . . . . . . . . . . . . . . . . . . . . . . 317 5.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 334 5.1.3 Epidemiology/Aetiology . . . . . . . . . 317 5.3.6.1 Recommended European 5.1.3.1 Risk Factors . . . . . . . . . . . . . . . . . . . . 318 Standard Diagnostic Steps 5.1.3.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . 318 of Investigation . . . . . . . . . . . . . . . . . 335 5.1.3.3 Incidence of AAA Rupture . . . . . . . 319 5.3.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 336 5.1.3.4 Disease Progression . . . . . . . . . . . . . 319 5.3.7.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 336 5.1.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 320 5.3.7.2 Endovascular Treatment . . . . . . . . . 338 5.1.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 320 References . . . . . . . . . . . . . . . . . . . . . . 341 5.1.4.1 Expanding Aneurysm . . . . . . . . . . . 320 5.1.4.2 Inflammatory AAA . . . . . . . . . . . . . . 320 5.4 Technically Challenging Cases 5.1.4.3 Rupture . . . . . . . . . . . . . . . . . . . . . . . . 320 for Endovascular Repair 5.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 321 of Aortic Aneurysms . . . . . . . . . . . . 343 5.1.5.1 Recommended European 5.4.1 Introduction . . . . . . . . . . . . . . . . . . . . 343 Standard Diagnostic Steps 5.4.2 Universally Challenging of Investigation . . . . . . . . . . . . . . . . . 321 Situations . . . . . . . . . . . . . . . . . . . . . . 343 5.1.5.2 Aspects on Screening . . . . . . . . . . . . 321 5.4.2.1 Vascular Access Morphology . . . . . 343 5.1.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 322 5.4.2.2 Aortic Aneurysm Configuration . . 343 5.1.6.1 Open Surgery . . . . . . . . . . . . . . . . . . . 322 5.4.3 Special Challenging Situations . . . . 347 5.1.6.2 Endovascular Aortic Repair 5.4.3.1 The Case of Aortic Arch (EVAR) . . . . . . . . . . . . . . . . . . . . . . . . 322 Aneurysm . . . . . . . . . . . . . . . . . . . . . . 347 5.1.6.3 Rupture and Reconstruction . . . . . 322 5.4.3.2 The Case of Aortic Dissection . . . . 347 5.1.6.4 Outcome . . . . . . . . . . . . . . . . . . . . . . . 323 5.4.3.3 The Case of Aortic Bronchial 5.1.7 Possible Complications and Enteric Fistula . . . . . . . . . . . . . . 349 of Surgery . . . . . . . . . . . . . . . . . . . . . . 323 5.4.3.4 Other Challenging Cases 5.1.8 Practical Recommendations . . . . . . 323 for EVAR . . . . . . . . . . . . . . . . . . . . . . . 350 References . . . . . . . . . . . . . . . . . . . . . . 323 5.4.4 Conclusion . . . . . . . . . . . . . . . . . . . . . 350 References . . . . . . . . . . . . . . . . . . . . . . 351 5.2 Treatment Options for Abdominal Aortic Aneurysm 5.5 Aortoiliac Occlusive Disease . . . . . 355 (AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 325 5.5.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 355 5.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 325 5.5.2 Synonyms . . . . . . . . . . . . . . . . . . . . . . 355 5.2.2 Open Repair . . . . . . . . . . . . . . . . . . . . 325 5.5.3 Definition . . . . . . . . . . . . . . . . . . . . . . 355 5.2.2.1 Complications . . . . . . . . . . . . . . . . . . 327 5.5.3.1 Morphological Features 5.2.3 Endovascular Repair . . . . . . . . . . . . 327 in the Chronic Forms . . . . . . . . . . . . 356 5.2.3.1 Complications . . . . . . . . . . . . . . . . . . 328 5.5.4 Epidemiology . . . . . . . . . . . . . . . . . . . 357 References . . . . . . . . . . . . . . . . . . . . . . 329 5.5.5 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 357 5.5.6 Symptoms . . . . . . . . . . . . . . . . . . . . . . 358 5.3 Inflammatory Aneurysms 5.5.6.1 Chronic AIOD . . . . . . . . . . . . . . . . . . 358 of the Abdominal Aorta . . . . . . . . . 331 5.5.6.2 Acute AIOD . . . . . . . . . . . . . . . . . . . . 359 5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 331 5.5.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 359 5.3.2 Definition . . . . . . . . . . . . . . . . . . . . . . 331 5.5.7.1 Recommended European 5.3.3 Epidemiology . . . . . . . . . . . . . . . . . . . 332 Standard . . . . . . . . . . . . . . . . . . . . . . . 359 5.3.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 333 5.5.7.2 Additional/Useful Diagnostic 5.3.4.1 Extension of Inflammation . . . . . . . 333 Procedures . . . . . . . . . . . . . . . . . . . . . 360
  16. 16. Contents XXI5.5.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 360 5.6.3 Totally Laparoscopic Operative5.5.8.1 Conservative Treatment . . . . . . . . . 360 Procedures . . . . . . . . . . . . . . . . . . . . . 3775.5.8.2 Endovascular and Surgical 5.6.3.1 Retrocolic or Prerenal Treatment . . . . . . . . . . . . . . . . . . . . . . 361 Transperitoneal Procedure as5.5.9 Differential Diagnosis . . . . . . . . . . . 363 Described by Coggia [8, 11] . . . . . . 3775.5.9.1 In the Case of Chronic AIOD . . . . 363 5.6.3.2 Combined Transperitoneal5.5.9.2 In the Case of Acute AIOD . . . . . . . 363 and Retroperitoneal Procedures . . 3795.5.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 363 5.6.3.3 Retroperitoneal Operation . . . . . . . 3805.5.11 Surgical and Endovascular 5.6.3.4 Direct Transperitoneal Principle . . . . . . . . . . . . . . . . . . . . . . . 364 Procedure [7] . . . . . . . . . . . . . . . . . . . 3805.5.11.1 Aortoiliac Angioplasty and 5.6.4 Instrumentation . . . . . . . . . . . . . . . . . 381 Stenting . . . . . . . . . . . . . . . . . . . . . . . . 364 5.6.4.1 Standard Laparoscopic5.5.11.1 Unilateral and Bilateral Instruments . . . . . . . . . . . . . . . . . . . . 381 Aortofemoral By-pass . . . . . . . . . . . 365 5.6.4.2 Specific Laparoscopic5.5.11.2 Unilateral or Bilateral Aortoiliac Instruments for Vascular By-pass . . . . . . . . . . . . . . . . . . . . . . . . . 366 Laparoscopy . . . . . . . . . . . . . . . . . . . . 3815.5.11.3 Aortic Exclusion and Bilateral 5.6.5 Complications . . . . . . . . . . . . . . . . . . 382 Aortoiliac or Bilateral 5.6.5.1 Intraoperative Complications . . . . 382 Aortofemoral Prosthetic 5.6.5.2 Early Postoperative Reconstruction . . . . . . . . . . . . . . . . . 367 Complications . . . . . . . . . . . . . . . . . . 3825.5.11.4 Unilateral or Bilateral 5.6.6 Current Indications and Results . . 383 Thoracoiliofemoral By-pass . . . . . . 367 5.6.7 Conclusions . . . . . . . . . . . . . . . . . . . . 3845.5.11.5 Aortoiliac Endarterectomy . . . . . . . 368 References . . . . . . . . . . . . . . . . . . . . . . 3845.5.11.6 Iliofemoral By-pass . . . . . . . . . . . . . . 3685.5.11.7 Femoro-femoral Cross-over 5.7 Aortouniiliac Endoprosthesis By-pass . . . . . . . . . . . . . . . . . . . . . . . . . 368 and Femoro-femoral Crossover5.5.11.8 Unilateral or Bilateral for AAA Repair . . . . . . . . . . . . . . . . . 387 Axillofemoral By-pass . . . . . . . . . . . 369 5.7.1 Introduction . . . . . . . . . . . . . . . . . . . . 3875.5.11.9 Retrograde Femoral 5.7.2 Definition . . . . . . . . . . . . . . . . . . . . . . 387 Embolectomy . . . . . . . . . . . . . . . . . . . 369 5.7.3 Indications . . . . . . . . . . . . . . . . . . . . . 3875.5.11.10 New Surgical Trends . . . . . . . . . . . . . 370 5.7.4 Contraindications . . . . . . . . . . . . . . . 3885.5.11.11 Aortobifemoral Video-assisted 5.7.5 Preoperative Management . . . . . . . 388 By-pass with Hand-Port System . . 371 5.7.6 Procedure . . . . . . . . . . . . . . . . . . . . . . 3885.5.11.12 Aortobifemoral Totally 5.7.7 Results and Complications . . . . . . . 389 Laparoscopic By-pass 5.7.8 Patency of the Femoro-femoral with Coggia’s Technique . . . . . . . . . 372 Crossover By-pass . . . . . . . . . . . . . . 390 References . . . . . . . . . . . . . . . . . . . . . . 373 5.7.9 Local Wound Complications, Graft Infection and Morbidity . . . 3915.6 Aortobifemoral By-pass: 5.7.10 Conclusion . . . . . . . . . . . . . . . . . . . . . 395 Laparoscopy-Assisted and References . . . . . . . . . . . . . . . . . . . . . . 395 Totally Laparoscopic Operative Procedures . . . . . . . . . . . . . . . . . . . . . 3755.6.1 Introduction . . . . . . . . . . . . . . . . . . . . 375 Visceral Arteries5.6.2 Operative Procedures . . . . . . . . . . . . 3755.6.2.1 Laparoscopy-Assisted Operative 6.1 Occlusive Disease of the Coeliac Procedures with Vascular and Superior Mesenteric Arteries . 401 Suturing by the Minimally 6.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 401 Invasive Route . . . . . . . . . . . . . . . . . . 375 6.1.2 Epidemiology . . . . . . . . . . . . . . . . . . . 401 6.1.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 401
  17. 17. XXII Contents 6.1.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 402 6.3.5.1 Thrombosis . . . . . . . . . . . . . . . . . . . . . 422 6.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 402 6.3.5.2 Embolism . . . . . . . . . . . . . . . . . . . . . . 422 6.1.5.1 Recommended European References . . . . . . . . . . . . . . . . . . . . . . 423 Standard Diagnostic Steps of Investigation . . . . . . . . . . . . . . . . . 402 6.1.5.2 Additional Useful Diagnostic Lower Extremity Arteries Procedures . . . . . . . . . . . . . . . . . . . . . 403 6.1.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 403 7.1 Lower Limb Arterial 6.1.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 404 Recanalization . . . . . . . . . . . . . . . . . . 427 6.1.6.2 Angioplasty . . . . . . . . . . . . . . . . . . . . . 406 7.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 427 6.1.7 Conclusion . . . . . . . . . . . . . . . . . . . . . 408 7.1.2 Problems and Questions . . . . . . . . . 427 References . . . . . . . . . . . . . . . . . . . . . . 408 7.1.2.1 Solved Problems . . . . . . . . . . . . . . . . 428 7.1.2.2 Unsolved Problems . . . . . . . . . . . . . . 428 6.2 Visceral Artery Aneurysms . . . . . . 411 7.1.2.3 Permanent Problems . . . . . . . . . . . . 430 6.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 411 7.1.2.4 Arising Questions . . . . . . . . . . . . . . . 430 6.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . 411 7.1.3 Conclusions . . . . . . . . . . . . . . . . . . . . 432 6.2.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 411 References . . . . . . . . . . . . . . . . . . . . . 433 6.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 412 6.2.5 Complications . . . . . . . . . . . . . . . . . . 412 7.2 Femorodistal By-pass Surgery . . . . 437 6.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 437 6.2.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.2 General Considerations . . . . . . . . . . 437 6.2.7.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.3 Operative Indications . . . . . . . . . . . . 438 6.2.7.2 Endovascular Therapy . . . . . . . . . . . 414 7.2.4 Technical Considerations . . . . . . . . 438 6.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 414 7.2.4.1 Proximal Anastomotic Site . . . . . . . 438 References . . . . . . . . . . . . . . . . . . . . . . 415 7.2.4.2 Graft Material . . . . . . . . . . . . . . . . . . . 439 7.2.4.3 Distal Anastomotic Site 6.3 Acute Ischaemia of the Visceral (Fig. 7.2.3) . . . . . . . . . . . . . . . . . . . . . . 441 Arteries . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.5 Special Considerations . . . . . . . . . . . 442 6.3.1 Acute Intestinal Ischaemia . . . . . . . 417 7.2.6 Graft Surveillance . . . . . . . . . . . . . . . 443 6.3.1.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.7 Results . . . . . . . . . . . . . . . . . . . . . . . . . 443 6.3.2 Acute Thrombotic or Embolic 7.2.7.1 Survival . . . . . . . . . . . . . . . . . . . . . . . . 443 Arterial Occlusion . . . . . . . . . . . . . . 417 7.2.7.2 Graft Patency and Limb Salvage . . 443 6.3.2.1 Epidemiology/Aetiology . . . . . . . . . 417 7.2.7.3 Quality of Life . . . . . . . . . . . . . . . . . . 445 6.3.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 417 References . . . . . . . . . . . . . . . . . . . . . . 445 6.3.2.3 Complications . . . . . . . . . . . . . . . . . . 418 6.3.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 418 7.3 Acute Ischaemia of the Lower 6.3.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 419 Extremities . . . . . . . . . . . . . . . . . . . . . 449 6.3.3 Mesenteric Venous Thrombosis . . 419 7.3.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 449 6.3.3.1 Epidemiology/Aetiology . . . . . . . . . 419 7.3.2 Definition . . . . . . . . . . . . . . . . . . . . . . 449 6.3.3.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 420 7.3.3 Epidemiology . . . . . . . . . . . . . . . . . . . 449 6.3.3.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 420 7.3.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 449 6.3.3.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 420 7.3.4.1 Embolism . . . . . . . . . . . . . . . . . . . . . . 449 6.3.4 Intestinal Ischaemia 7.3.4.2 Thrombosis . . . . . . . . . . . . . . . . . . . . . 450 after Aortoiliac Surgery . . . . . . . . . . 420 7.3.4.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.1 Epidemiology/Aetiology . . . . . . . . . 420 7.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.1 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 6.3.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.2 Paraesthesia . . . . . . . . . . . . . . . . . . . . 451 6.3.4.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.3 Paralysis . . . . . . . . . . . . . . . . . . . . . . . . 451 6.3.5 Acute Renal Ischaemia . . . . . . . . . . . 422 7.3.5.4 Pallor . . . . . . . . . . . . . . . . . . . . . . . . . . 452
  18. 18. Contents XXIII7.3.5.5 Pulselessness . . . . . . . . . . . . . . . . . . . . 452 7.5 Buerger’s Disease of the Lower7.3.6 Complications . . . . . . . . . . . . . . . . . . 452 Extremities . . . . . . . . . . . . . . . . . . . . . 4717.3.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 452 7.5.1 Synonym . . . . . . . . . . . . . . . . . . . . . . . 4717.3.7.1 Recommended European 7.5.2 Definition . . . . . . . . . . . . . . . . . . . . . . 471 Standard Diagnostic Steps 7.5.3 Epidemiology . . . . . . . . . . . . . . . . . . . 471 of Investigation . . . . . . . . . . . . . . . . . 452 7.5.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 4717.3.7.2 Additional Useful Diagnostic 7.5.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 472 Procedures . . . . . . . . . . . . . . . . . . . . . 453 7.5.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 4737.3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 453 7.5.6.1 Recommended European7.3.8.1 Conservative Treatment . . . . . . . . . 453 Standard Diagnostic Steps7.3.8.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 453 of Investigation . . . . . . . . . . . . . . . . . 4737.3.8.3 Thrombolytic Therapy . . . . . . . . . . . 455 7.5.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 4767.3.9 Differential Diagnosis . . . . . . . . . . . 457 7.5.7.1 Conservative Treatment . . . . . . . . . 4767.3.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 457 7.5.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 476 References . . . . . . . . . . . . . . . . . . . . . . 457 7.5.7.3 Differential Diagnosis . . . . . . . . . . . 477 7.5.7.4 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 4777.4 Lower Extremity Aneurysms . . . . . 459 References . . . . . . . . . . . . . . . . . . . . . . 4777.4.1 Basic Concepts . . . . . . . . . . . . . . . . . . 4597.4.2 Popliteal Aneurysms (PA) . . . . . . . . 459 7.6 Popliteal Artery Entrapment7.4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 460 and Popliteal Adventitial Cystic7.4.2.2 Epidemiology/Aetiology . . . . . . . . . 460 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 4797.4.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 460 7.6.1 Definition . . . . . . . . . . . . . . . . . . . . . . 4797.4.2.4 Complications . . . . . . . . . . . . . . . . . . 460 7.6.2 Epidemiology/Aetiology . . . . . . . . . 4797.4.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 460 7.6.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 4797.4.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 461 7.6.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 4807.4.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . 462 7.6.4.1 Recommended European7.4.3 Aneurysms of the Common Standard Diagnostic Steps Femoral Artery . . . . . . . . . . . . . . . . . 462 of Investigation . . . . . . . . . . . . . . . . . 4807.4.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 462 7.6.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 4817.4.3.2 Epidemiology/Aetiology . . . . . . . . . 462 7.6.5.1 Recommended European7.4.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 463 Standard Surgical Procedures . . . . 4817.4.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 464 7.6.6 Special Remarks . . . . . . . . . . . . . . . . . 4837.4.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 464 References . . . . . . . . . . . . . . . . . . . . . . 4847.4.3.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 4667.4.4 Aneurysms of the Superficial 7.7 Vascular Trauma of the Lower Femoral Artery . . . . . . . . . . . . . . . . . 466 Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . 4857.4.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 466 7.7.1 The Problem . . . . . . . . . . . . . . . . . . . . 4857.4.4.2 Epidemiology/Aetiology . . . . . . . . . 467 7.7.1.1 Encountering Vascular Injury . . . . 4867.4.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 467 7.7.1.2 How Can Ischaemia of the7.4.4.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 467 Lower Limb be Detected7.4.4.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 467 or Ruled Out Reliably? . . . . . . . . . . . 4867.4.4.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 467 7.7.2 Mechanisms of Injury . . . . . . . . . . . 4887.4.5 Aneurysms of the Distal 7.7.2.1 Sharp Injury . . . . . . . . . . . . . . . . . . . . 488 Branches . . . . . . . . . . . . . . . . . . . . . . . 468 7.7.2.2 Blunt injury . . . . . . . . . . . . . . . . . . . . . 4887.4.5.1 Epidemiology/Aetiology . . . . . . . . . 468 7.7.2.3 Iatrogenic . . . . . . . . . . . . . . . . . . . . . . 4907.4.5.2 Clinical Symptoms . . . . . . . . . . . . . . 468 7.7.3 Consequences of Arterial Injury7.4.5.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 468 of the Lower Limb . . . . . . . . . . . . . . 4937.4.5.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 468 7.7.3.1 Compartment Syndrome . . . . . . . . 493 References . . . . . . . . . . . . . . . . . . . . . 468
  19. 19. XXIV Contents 7.7.3.2 False Aneurysms and Arterio- 9.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 525 Venous Fistulas . . . . . . . . . . . . . . . . . 494 9.1.1.1 Scope of the Problem . . . . . . . . . . . . 525 7.7.4 The Management of Vascular 9.1.2 Incidence and Morbidity Trauma (With Special Reference of Amputation . . . . . . . . . . . . . . . . . . 525 to the Knee Joint) . . . . . . . . . . . . . . . 494 9.1.3 Classification and Indications . . . . 526 7.7.5 Bulleted Summary . . . . . . . . . . . . . . 497 9.1.3.1 Emergency Amputation . . . . . . . . . 526 References . . . . . . . . . . . . . . . . . . . . . . 497 9.1.3.2 Elective Amputations . . . . . . . . . . . . 526 9.1.4 Determination of Amputation Level . . . . . . . . . . . . . . . . . . . . . . . . . . . 527 Diabetic Foot 9.1.4.1 Transcutaneous Oxygen Tension (PtCO2) Measurement . . . . . . . . . . . 528 8.1 Diabetic Foot . . . . . . . . . . . . . . . . . . . 501 9.1.4.2 Clearance of [133Xe] . . . . . . . . . . . . . 528 8.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 501 9.1.5 Preoperative Management . . . . . . . 528 8.1.2 Epidemiology . . . . . . . . . . . . . . . . . . . 501 9.1.6 Surgical Techniques of 8.1.2.1 Foot Ulcers . . . . . . . . . . . . . . . . . . . . . 501 Amputation . . . . . . . . . . . . . . . . . . . . 528 8.1.2.2 Amputation . . . . . . . . . . . . . . . . . . . . . 501 9.1.6.1 Toe Amputation . . . . . . . . . . . . . . . . . 528 8.1.2.3 Social and Economic Costs . . . . . . . 502 9.1.6.2 Ray Amputation . . . . . . . . . . . . . . . . 529 8.1.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 503 9.1.6.3 Transmetatarsal Amputation . . . . . 530 8.1.3.1 Pathogenesis of the Neuropathic 9.1.6.4 Syme’s Amputation Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 (Ankle Disarticulation) . . . . . . . . . . 531 8.1.3.2 Pathogenesis of the Ischaemic 9.1.6.5 Below-knee Amputation . . . . . . . . . 532 Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 9.1.6.6 Above-knee Amputation . . . . . . . . . 533 8.1.4 Complications: Neuro- 9.1.6.7 Amputation of the Upper Osteoarthropathy . . . . . . . . . . . . . . . 506 Extremity . . . . . . . . . . . . . . . . . . . . . . 534 8.1.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 506 9.1.7 Postoperative Considerations 8.1.4.2 Epidemiology . . . . . . . . . . . . . . . . . . . 506 and Rehabilitation . . . . . . . . . . . . . . . 534 8.1.4.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 507 9.1.8 Complications . . . . . . . . . . . . . . . . . . 535 8.1.4.4 Symptoms/Investigations/ References . . . . . . . . . . . . . . . . . . . . . . 535 Diagnosis/Treatment . . . . . . . . . . . . 507 8.1.5 Diagnosis/Investigations . . . . . . . . . 507 8.1.5.1 Clinical Examination . . . . . . . . . . . . 507 Venous Diseases 8.1.5.2 Circulation . . . . . . . . . . . . . . . . . . . . . 508 8.1.5.3 Paraclinical Evaluation . . . . . . . . . . 509 10.1 Chronic Venous Insufficiency . . . . 539 8.1.5.4 Classification Systems . . . . . . . . . . . 509 10.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 539 8.1.6 Differential Diagnosis . . . . . . . . . . . 509 10.1.2 Functional Anatomy and 8.1.7 Infections . . . . . . . . . . . . . . . . . . . . . . . 510 Physiology of the Venous System . . 539 8.1.7.1 Introduction . . . . . . . . . . . . . . . . . . . . 510 10.1.2.1 Superficial Veins . . . . . . . . . . . . . . . . 539 8.1.7.2 Pathophysiology . . . . . . . . . . . . . . . . 511 10.1.2.2 Deep Veins . . . . . . . . . . . . . . . . . . . . . 539 8.1.7.3 Microbiology . . . . . . . . . . . . . . . . . . . 512 10.1.2.3 Perforating Veins . . . . . . . . . . . . . . . . 539 8.1.7.4 Clinical Presentation . . . . . . . . . . . . 512 10.1.3 Chronic Venous Insufficiency . . . . 539 8.1.7.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 513 10.1.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 539 8.1.7.6 Severity Classification . . . . . . . . . . . 514 10.1.3.2 Epidemiology/Aetiology . . . . . . . . . 540 8.1.7.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 515 10.1.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 541 8.1.8 Treatment of the Diabetic Ulcer . . 517 10.1.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 543 References . . . . . . . . . . . . . . . . . . . . . . 518 10.1.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 545 10.1.3.6 Conclusion . . . . . . . . . . . . . . . . . . . . . 549 References . . . . . . . . . . . . . . . . . . . . . . 549 Amputations 10.2 Deep Venous Thrombosis . . . . . . . . 551 9.1 Amputation of Extremities . . . . . . . 525 10.2.1 Epidemiology/Aetiology . . . . . . . . . 551

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