Postgraduate Vascular Surgery

The following sections are included:

• Preface
• List of Contributors
• Contents

The following sections are included:

• One long and three short cases in the FRCS clinical exam in 30 minutes.
• Previous practice to examine in a systematic manner with a senior colleague in an outpatient setting is useful.
• The initial starter question may lead to more complex issues.
• Patients usually stable elderly mobile patients.
• Short cases usually a pool of cases with venous ulcers, KTS or carotid tumours.

The following sections are included:

• Peripheral arterial disease (PAD) is an under-diagnosed, under-treated condition and its prevalence is increasing.
• Patients with PAD have a cardiovascular risk profile equivalent to or worse than those with coronary or cerebrovascular disease.
• PAD patients with concomitant symptomatic cardiac or cerebrovascular disease, diabetes or a low ankle pressure index are at even higher risk of sustaining a vascular event.
• Patients with PAD should receive the same risk factor management as patients with other cardiovascular diseases.
• Patient awareness of the need for cardiovascular secondary prevention therapy in PAD is low.
• All PAD patients should be prescribed antiplatelet (clopidogrel preferably, if not on an anticoagulant) and statin, if tolerated.

The following sections are included:

• New oral anticoagulants (NOACs) are growing in popularity as an alternative to warfarin.
• No monitoring of coagulation is required.
• Fixed once or twice daily dosing.
• Bridging with low molecular weight heparin (LMWH) is not required when commencing treatment with NOACs due to their quick onset of action.
• Dose adjustments are required in renal failure.
• NOACs have a favourable safety profile in comparison to warfarin, but care is required for the elderly who may be at risk of a gastrointestinal bleed.
• NOACs can be used in VTE prevention for elective orthopaedic surgery, VTE treatment and prevention of arterial thromboembolism in patients with atrial fibrillation.
• NOACs are not yet recommended for anticoagulation control in patients with prosthetic heart valve and acute coronary syndrome.

The following sections are included:

• Acute limb ischaemia (ALI) is associated with significant mortality and morbidity.
• Clinical assessment is paramount for planning management.
• All cases of ALI should be assessed by a vascular specialist.
• All cases should be started on intravenous heparin as soon as possible to prevent extension of thrombus.
• Surgery is preferred with severe ALI as time is of essence.
• Thrombolysis is associated with a lower mortality rate but higher failure rates.
• Surgery is more durable but is associated with a higher mortality rate.
• If compartment syndrome is likely or suspected, a fasciotomy is required.

The following sections are included:

• Peripheral arterial disease (PAD) affects approximately 30% of the adult population.
• PAD is a powerful marker of cardiovascular risk and the risk is related to the severity of PAD.
• Risk factor management has been proven to reduce cardiovascular risk, but many patients do not receive adequate treatment.
• The optimum treatment to improve walking in patients with intermittent claudication is best medical treatment (BMT) and supervised exercise, with angioplasty for those who do not improve with exercise therapy.
• Angioplasty and surgery appear to be equivalent in treating critical limb ischaemia (CLI), but there is insufficient evidence comparing long-term outcomes. Angioplasty is cheaper due to reduced length of hospital stay, but surgery is better for patients who survive over 2 years. There is some evidence that patients have worse outcomes if they undergo surgery after having endovascular intervention.
• Diabetic foot complications are a common cause of hospital admission and often precede amputation. The majority of amputations in the UK are carried out in patients with diabetes, and many of these are avoidable.
• Patients with diabetes should be screened annually for neuropathy and PAD and those at increased risk of foot ulceration seen regularly in a specialised foot clinic.
• Multi-professional team approach to the management of diabetic foot complications and timely recognition and treatment of the acute diabetic foot can reduce amputation rates.

The following sections are included:

• Endovascular practice involves three key elements:
  • Safe Access: How to get into a blood vessel safely. Ultrasound-guided Seldinger technique allows a safe approach to the arterial system. The common femoral is the most frequently used access site, but alternative access approaches like the brachial, popliteal, radial and tibiopedal also have benefits.
  • Safe Navigation: An understanding of the tools which can be used inside blood vessels. Guidewires have a central core and outer covering which determine their behaviour. Catheters are sized in French (Fr) which refers to their outer diameter. They come in a range of lengths and sizes and allow injection of contrast and a way to steer and support the guidewire.
  • Safe Closure: How to safely close the vessel at the end of a procedure. Manual compression of a vessel is a safe way to close a vessel but closure devices can produce quicker haemostasis and earlier ambulation. Vascular access up to 24Fr can also be closed percutaneously with pre-deployed suture mediated devices.

The following sections are included:

• Risk factor optimisation and best medical therapy are the standard of care for all patients.
• Severe acute ischaemia is best managed with surgery, there is a role for thrombolysis in less severe cases.
• Thrombolysis requires intensive monitoring to identify and manage complications.
• Surgical or endovascular revascularisation is appropriate for patients with limiting claudication or critical limb ischaemia.
• Non-invasive imaging should be used for procedural planning.
• Bypass grafts with autologous vein produce the best long-term patency rates.
• Endovascular procedures have lower mortality and morbidity rates than the equivalent surgery.
• Stents and stent grafts improve endovascular results and are important for managing complications.
• Patient fitness, comorbidity and preference are as important as lesion characteristics in informing revascularisation decisions.
• Multi-disciplinary teams are best placed to manage individual patients in this rapidly evolving field.

The following sections are included:

• An aneurysm is an abnormal dilatation of a vessel to greater than 50% normal size.
• Smoking, male gender, hypertension and genetics are the main risk factors for abdominal aortic aneurysm (AAA).
• The annual risk of rupture for an AAA of 5–5.9 cm is 5%.
• Contrast enhanced tomography (computed tomography, CT) is the gold standard for measuring the size of an aneurysm and planning intervention.
• The UK small aneurysm trial (UKSAT) helped reach a consensus about the minimal size at which aneurysms should be treated — usually 5.5 cm in the UK.
• The UK endovascular aneurysm repair trial (EVAR) 1 showed better early results for EVAR vs. open surgery, although after 2 years there was no benefit and at 15 years EVAR was inferior.
• The UK EVAR 2 trial in unfit patients showed no difference between endovascular and open repair in unfit patients.
• The IMPROVE, AJAX and the ECAR trials showed similar mortality for endovascular vs. open repair for ruptured aortic aneurysms.

The following sections are included:

• Aneurysm disease affects the thoracic aorta much less commonly than the infrarenal aorta.
• Most patients are asymptomatic, but may have chest, back or abdominal pain.
• Diagnosis is on computed tomography (CT) angiogram and the Crawford classification is used to describe the extent of the aneurysm.
• Intervention is recommended if the aneurysm is >6 cm (or 5 cm in the presence of a connective tissue disorder or a family history of rupture).
• Open surgery remains the standard treatment for complex suprarenal, thoracic and thoracoabdominal aneurysms.
• Specific complications include risks of paraplegia and renal and visceral ischaemia.
• Endovascular repair is suitable for descending thoracic aneurysms.

The following sections are included:

• Aortic dissection may be defined according to the time since onset of symptoms as hyperacute (<24 h), acute (2–7 days), subacute (8–30 days) or chronic (>30 days).
• Acute aortic dissection is associated with hypertension and pre-existing disease of the aortic wall.
• Patients usually present with severe, tearing chest and back pain.
• Diagnosis is with transoesophageal echocardiogram and computed tomography (CT) angiogram.
• The Stanford or DeBakey classifications are used to describe the pattern of dissection.
• Type A dissections require early surgical treatment. The in-hospital mortality is high, but the prognosis is very good in patients surviving to discharge from hospital.
• Type B dissections are treated medically in the first instance. The in-hospital mortality is much lower compared to type A, but complications may occur following discharge.
• Chronic type B dissection may result in aortic dilatation and rupture, so surveillance is required.
• There is an expanding role for early endovascular intervention.

The following sections are included:

• The majority of femoral artery aneurysm (FAA) present with local symptoms or thigh pain or claudication.
• Type I aneurysms involves the CFA only and type II involves the CFA and SFA.
• The majority can be repaired using straight or bifurcated interposition grafts.
• Pseudo aneurysms form as a result of IV drug abuse or iatrogenic injury from catheterisation.
• Most small pseudo aneurysms less than 3 cm have an indolent course and can be managed conservatively.
• Symptomatic ones can do treated with ultrasound guided compression or thrombin injection.

The following sections are included:

• Popliteal artery aneurysm (PAA) is the most common lower limb aneurysm.
• PPAs rarely occur in isolation.
• The majority present either as an incidental finding or as lower limb ischaemia.
• Aneurysm rupture is rare, but life and limb threatening when it occurs.
• All symptomatic PAAs should undergo repair.
• Asymptomatic PAAs >2 cm in maximum diameter should be considered for repair.
• Adequate imaging of the proximal and distal vasculature is vital for successful repair.
• Endovascular repair has promising results but the evidence base is still relatively weak.

The following sections are included:

• The extracranial arteries are prone to involvement with a number of important atherosclerotic and non-atherosclerotic conditions.
• The provision of best medical therapy should not be delegated to the most junior member of the team. It is an essential component of care.
• Patients with symptomatic carotid disease benefit from very rapid intervention. Investigative strategies and rapid access to the operating theatre should be geared to ensuring all patients are treated within 2 weeks of suffering their index symptom.
• Relatively few patients with asymptomatic carotid disease benefit from intervention (especially females and patients aged >75 years). It is essential that trials identify high-risk subgroups.
• The role of several technical aspects of carotid surgery have been guided by large randomised trials.
• Patients with symptomatic vertebral stenoses may have a much worse prognosis than was previously thought, but there is no compelling evidence that stenting confers significant benefit over medical therapy.

The following sections are included:

• Thoracic outlet syndrome (TOS) is caused by compression on neurovascular bundle in the thoracic outlet tunnel.
• TOS can be neurogenic (90%), venous (5%), arterial (1%), or any combination of the above three.
• Physical examination is more reliable in the venous and arterial forms but is not straightforward in the neurologic form where more objective tests are required.
• Provocative tests have high false positive rates.
• Dynamic imaging has more diagnostic value than standard imaging.
• Neurologic TOS should be referred to physiotherapy for postural correction and muscle exercise.
• Venous and arterial TOS are treated with surgical decompression and blood vessel reconstructive procedures. The rule is ‘the sooner, the better’.

The following sections are included:

• Chronic mesenteric ischaemia (CMI) is a rare condition, accounting for less than 5% of all intestinal ischaemic events.
• More than 90% of the cases are due to atherosclerotic occlusion or severe stenosis.
• Classic symptoms include post-prandial abdominal pain, sitophobia, and weight loss.
• At least two of the three main splanchnic arteries must be significantly compromised to result in CMI.
• Duplex ultrasonography is non-invasive and expedient, but may miss up to 20% of vascular lesions in celiac artery.
• Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are equally excellent non-invasive modalities with highly accurate diagnosis.
• Digital Subtraction angiography should be reserved for the diagnosis of CMI only when other modalities have been unhelpful or if intervention such as percutaneous transluminal angioplasty (PTA) is planned.
• Surgical vascular bypass is the definitive therapy for CMI with an overall 5-year graft patency of 78%. It is preferred in younger patients with less comorbidities.
• Endovascular therapy is optimal in short segment atherosclerotic lesions <2 cm from the ostia of coeliac and superior mesenteric artery. Angioplasty and stenting have a significantly lower rate of complications although the intervention rate is higher.

The following sections are included:

• Acute ischaemic colitis can be due to occlusive or non-occlusive causes.
• A high index of suspicion should be present in elderly patients presenting with sudden abdominal pain and bloody diarrhea.
• Computed tomography (CT) scan may show a ‘halo sign’ and also rule out other abnormalities.
• D Lactate is more specific for intestinal ischaemia.
• Angiography and lysis may be considered in early cases with no sign of peritonitis.
• In the case of bowel resection, primary anastomosis is best avoided and a relook laparotomy recommended.
• Postaneurysm repair colitis can be prevented by selective reimplantation of the inferior mesenteric artery (IMA) in high risk cases.

The following sections are included:

• Remember the whole patient, do not just focus on the vascular injury.
• Time is of the essence, avoid delay.
• Massive haemorrhage is the major preventable cause of death after major trauma.
• Do not attempt to mobilise large veins, use local pressure.
• Consider temporary intravascular shunts in complex limb injuries.
• Consider damage limitation surgery in patients developing hypothermia or acidosis.

The following sections are included:

• Peripheral vascular disease is the leading cause of amputation in the Western world.
• Diabetics are 8–12 times more likely to suffer amputation.
• Mortality and subsequent loss of the contralateral limb following amputation are high.
• The level of amputation requires careful consideration of the rehabilitative potential of the patient, level and pattern of vascular disease and likely healing.
• Careful pre-operative assessment and peri-operative care using the multidiscliplinary team is essential for successful outcomes.
• Epidural analgesia provides the best peri-operative analgesia, but does not prevent subsequent phantom pain.
• The general principles of amputation surgery apply to all sites of amputation.
• Rehabilitation of the patient should start immediately post-operatively.
• Post-amputation pain is the commonest post-operative complication, is multifactorial and requires thorough assessment and possible onwards referral to a multidisciplinary pain team for management.
• Phantom limb pain is common and effective treatments remain elusive.

The following sections are included:

• Worldwide, the commonest cause of lymphoedema is filariasis.
• In the Western world, the commonest cause is malignancy and its treatment.
• Oedema is initially pitting, but becomes non-pitting due to fibrosis of subcutaneous tissues.
• Diagnosis is confirmed by isotope lymphangioscintigraphy.
• Satisfactory treatment can usually be achieved by conservative measures that include manual drainage, compression hosiery, complex decongestive therapy and prevention of infection.

The following sections are included:

• Truncal varices are common with an age-adjusted prevalence of 40% in men and 32% in women.
• Varicosities may be primary, or secondary due to previous deep vein thrombosis (DVT), pelvic obstruction or deep venous reflux.
• Patients present with discomfort, aching, swelling, pain, pruritus, bleeding, thrombophlebitis and skin changes.
• Hand-held Doppler has replaced the tourniquet test as a ‘bedside examination’ for evaluating venous reflux. Patients having treatment will normally undergo duplex scanning.
• Surgery involves high tie and stripping and has a recurrence rate of 15–20%. It has been largely replaced by less invasive catheter ablation techniques.
• Foam sclerotherapy and catheter ablation techniques can be performed under local anaesthesia. Tumescent anaesthesia is used for laser and radiofrequency ablation. Tumescent anaesthesia is not required for mechanochemical ablation and cyanoacrylate ablation.
• Chronic venous insufficiency affects between 7% and 9% of the adult population and is due to venous reflux, outflow obstruction and calf pump failure.
• Clinical signs include swelling, venous eczema, pigmentation, lipodermatosclerosis and ulceration.
• Multilayered compression bandaging is the gold standard for healing venous ulceration compression.
• Venous reconstruction is rarely performed, but there remains a role for venous bypass surgery. The use of venous angioplasty and stenting is increasing.

The following sections are included:

• Clinical signs of chronic venous insufficiency (CVI) include swelling, venous eczema, pigmentation, lipodermatosclerosis and ulceration.
• The main area for venous change and ulceration is the medial calf “gaiter” area.
• The mechanisms involved are venous reflux, outflow obstruction and calf pump failure or a combination of these.
• Many cases (c. 50%) follow DVT when they are termed the postthrombotic syndrome.
• Multi-layered compression bandaging is the gold standard for healing venous ulceration.
• Graduated compression stockings are used to maintain healing.
• All venous ulcer patients should be referred for a duplex scan.
• Those with superficial venous incompetence should be offered surgical intervention.
• Graduated compression is contraindicated in the presence of significant peripheral arterial disease.
• Venous reconstruction is rarely performed, but there remains a role for venous bypass surgery for deep venous obstruction.
• The use of deep venous angioplasty and stenting is increasing and has good results in selected patients.

The following sections are included:

• Deep vein thrombosis (DVT) and pulmonary embolism (PE) are the leading causes of preventable in-patient mortality following surgery.
• Many DVTs are asymptomatic, but are still a risk for PE.
• Validated clinical prediction rules should be used to estimate the pretest probability of venous thromboembolism (VTE), e.g., Wells score.
• D-dimer level measurements are useful screening tests.
• Ultrasonography is the current first-line imaging investigation for DVT.
• Newer anticoagulants such as rivaroxaban and dabigatran are now being used for prophylaxis and treatment of VTE.
• Inferior vena caval filters (IVCFs) should be used when anticoagulation is contraindicated or further VTE occurs despite adequate anticoagulation.
• DVT can lead to post-thrombotic syndrome (PTS) in the longer term.
• Thrombolysis should be considered in younger, fitter patients with ileofemoral DVT to reduce PTS risk.

The following sections are included:

• Infection of prosthetic vascular grafts is associated with high mortality, morbidity and limb loss.
• Prosthetic grafts should be avoided if the risk of infection is high.
• Early diagnosis requires a low index of suspicion.
• The greatest chance of long-term success lies in complete removal of the infected prosthesis and revascularisation with autologous material.
• A groin abscess in an intravenous drug abuser should be considered to be an infected false aneurysm of the femoral artery until positively excluded.

The following sections are included:

• Assessment of haemorrhage should include classification of haemorrhage severity and checking blood parameters including full blood count (FBC), coagulation parameters, fibrinogen level, renal function and liver function tests.
• Peri-operative management of haemorrhage includes activation of the major haemorrhage protocol, administration of oxygen and IV fluids and early surgical or endovascular intervention to stop the bleeding.
• Acidosis and hypothermia are confounding factors which can exacerbate bleeding and should be addressed.
• Targeted procoagulation interventions should be considered, which include administration of fibrinogen, cryoprecipitate, FFP and platelets.
• Antifibrinolytic agents and recombinant factor VIIa can have a role.
• Antidotes are now available for most of the antithrombotic drugs including the new oral anticoagulants (NOACs).
• Post-operatively, antithrombotic therapy or venous thromboembolism (VTE) prophylaxis should be recommenced once haemostasis has been achieved.

The following sections are included:

• In the neonate, differentiate between haemangioma and vascular malformation.
• Clinical assessment is of prime importance.
  • Is intervention or simple reassurance required?
  • Realistically manage patient and parent expectations.
• Investigate by ultrasound, Duplex and magnetic resonance imaging (STIR, T1 and T2 with selective use of magnetic resonance angiography and magnetic resonance venography).
• Invasive angiography rarely indicated except for complex arteriovenous (AV) malformations and planned embolisation; identify the nidus.
• Classify the malformation — extra-truncular or truncular, high or low flow, ISSVA Classification?
• The majority of congenital vascular malformations (CVMs) are venous
  • Investigate for coagulopathy (DIC) in diffuse extensive capillary/venous malformations in the young child and adult.
• Malignant vascular malformations are rare.
• Tailor treatment to the severity of the lesion
  • Cosmesis, pain, function, asymmetry, tissue damage, etc.
• Foam sclerotherapy will be suitable and repeatable for the majority of venous malformations.
• Klippel–Trénaunay and Parkes-Weber syndromes and high flow malformations will need multidisciplinary input
  • Vascular and endovascular, orthopaedic, plastic surgeons, paediatrician and dermatologist.
• Look for and ablate ectatic and aneurysmal lateral marginal and deep veins because of risk of thromboembolic disease and death.
• Ethanol sclerotherapy and surgery for the minority, usually high flow AV malformations.
• The best care for patients of all age groups with CVMs is provided by multidisciplinary groups (including plastic surgery) with a special interest.

The following sections are included:

• Understanding of the nomenclature used for the classification of vasospastic disorders into primary and secondary Raynaud’s phenomena (RP) is essential.
• The management of these disorders requires a multidisciplinary team approach involving physicians, rheumatologists and vascular specialists.
• Treatment of Raynaud’s includes general supportive measures, pharmacotherapy and correction of underlying disorders.
• Vasculitis is associated with a range of medical conditions and can present as digital ischaemia.
• A diagnosis of vasculitis is suggested by constitutional symptoms and confirmed by raised inflammatory markers, the presence of autoantibodies, targeted radiological imaging and biopsy of skin lesions or other involved organs.
• Immunosuppressive therapy is the mainstay of treatment in vasculitic disorders.

The following sections are included:

• The population requiring dialysis is increasing by 5–6% worldwide and costs the NHS more than £1 billion per year.
• Therapy includes transplantation, peritoneal and haemodialysis (HD).
• Adequate HD requires relatively painless, durable, problem free access.
• This chapter aims to give a framework for assessment, planning best access and dealing with complications.

The following sections are included:

• Postganglionic sympathetic C fibres supply control the sweat gland function.
• Primary hyperhidrosis can impair the social, professional, psychological and physical aspects of patients’ lives.
• Local referral pathways and stepwise management protocols should be adopted by the multidisciplinary group.
• Conservative treatments such as topical treatment and iontophoresis should be tried first and patient compliance makes a difference.
• Botulin toxin injections are effective and well received by patients especially for the axillary and facial forms but repeated injections are required.
• Thoracoscopic sympathectomy of T2, T3 for palmar and T2, T3, T4 ganglia for axillary hyperhidrosis is effective and a lifelong solution.
• Extensive consultation should always take place and patients must be warned about complications especially compensatory sweating and the irreversibility of these procedures.
• Local surgical treatments such as elliptical excision, curettage and liposuction for axillary form are effective and less invasive.

The following sections are included:

• Peri-operative cardiac complications are the most serious risks to delineate and pre-emptively manage.
• Discussions between anaesthetists, surgeons and cardiologists are frequently required on a case-by-case basis.
• Critical care is an essential and rapidly developing support to many surgical procedures.

The following sections are included:

• Solid organ transplantation is now commonplace and is the standard of care for patients with end-stage organ failure.
• Indications have changed over time and there are few absolute contraindications.
• Equity of access to transplant waiting lists is paramount and selecting the correct recipient and donor pair will optimise the outcome.
• The surgical techniques for all organ transplantation are now well established and standardised, and as a result there has been a year-on-year improvement in 1-year survival. Most recipients die because of comorbidity or poor organ function.
• Live donor transplantation for both kidney and liver recipients has become an extremely important source of donor organs.
• Complications are general to surgical patients, but indeed each organ has its own specific risks.
• Immunosuppression has advanced hugely over the past 10 years and, as a result, the overall attrition rate due to acute rejection has reduced considerably.
• The biggest problem facing transplantation today is the donor shortage. Over the next 5 years the organ donor taskforce set up by the Minister of Health has set out a plan to increase donation by 50%.
• Until this happens, transplantation will always have to deal with the ethical dilemmas of allocation, utilisation and fairness.

The following section is included:

• Index