C:\Users\Kubenstein\Desktop\Aortic.jpg Vascular surgery Dr.Lukáč Jakub FN Brno –Trauma dept. C:\Users\Kubenstein\Desktop\atheroma-drawing-DF8XJR.jpg ...little bit of history first —Studies on egyptian mummies revealed, that people more than 3500 yrs back suffer from atherosclerosis —Ebers Papyrus (2000 b.c.)-identified peripheral arterial aneurysms, and suggested forms of treatment , e.g. „treat it with a knife, and burn it with a fire, so it doesnt bleed so much“ LOL :D —Hippokrates (400 b.c.) – treated hemorrhoids by putting a red –hot iron in patients anus (first cautherization) —Antyllus (2 century a.d.)- invented a ligature system, in which he applied ligatures to arteries entering and leaving the aneurysm, then cutting the sac of aneurysm, and packing the cavity —Ambroise Paré (16th century) – starts using ligations, stops with boiling oil and cautherization — — Dark ages treatment of hemorrhoids with hot iron — C:\Users\Kubenstein\Desktop\hemorroidas-na-idade-media.jpg Please, kill me! What is vascular surgery? —Vascular surgery is surgical subspecialty, which is dealing with diseases of vascular system, including lymphatic venous system. —Todays trend is to treat as much as possible conservatively, with medication, or using minimally – invasive procedures. —When need arises, open surgery of vascular reconstruction is done. —Vascular surgeon treats vascular problems,except for heart and brain vacular conditions. What are the most common vascular diseases? —Abdominal aortic aneurysm —Aortic dissection —Atherosclerosis —Chronic venous insufficiency —Deep venous thrombosis —Peripheral arterial disease —Thoracic aortic aneurysm —Varicose veins —Haemorrhoids —Vascular trauma —Pulmonary embolism —Lymphedema —Carotid artery disease —and other.... C:\Users\Kubenstein\Desktop\50072664-stock-vector-aneurysm-types-aneurysm-infographics-.jpg Aneurysms —Abnormal, localized weak spot on artery wall, that causes the wall to bulge outward, like a baloon. —Aneurysms may be divided due to localization, shape, —or mural structure. — C:\Users\Kubenstein\Desktop\Types+of+Aneurysms%2F+Layers (1).jpg Shapes — C:\Users\Kubenstein\Desktop\Classification-model-of-aneurysms-according-to-shape-into-globoid-pear- shaped-bilobar.png Some statistics —-prevalence of AA in older than 65 yrs is 3-4 % —-prevalence in thoracic AA is 6 cases in 100 000 people —-males suffer more often than females —-in last 30.yrs, prevalence of aortic aneurysms has increased —-incidence is increased also — Signs and symptoms-thoracic aneurysm —-in many patients it is discovered incidentally -depending on the affected part of the aorta —Ascending thoracic aorta aneurysm: —-pain in neck, chest or back —-swelling of head, neck, extremities —-heart failure due to aortic valve regurgitation, distal embolism, rupture —Aortic arch and descending aorta aneurysm: —-wheezing,coughing, shortness of breath – trachea compression —-dysphagia, chest pain, hoarseness other signs and symptoms.... —Heart murmurs —Paraparesis/paraplegia —Substantial part of all aortal dilatations remains asymptomatic —Hemoptysis, hematemesis —Nausea —Constipation —Tachycardia, sweaty skin C:\Users\Kubenstein\Desktop\AAA 3D.jpg Abdominal aorta aneurysm — Enlargement of aorta below diaphragm — Dilatation over 3 cm is considered an aneurysm — Diagnostics —Anamnesis —Physical examination —Clinical presentation —Laboratory —ECG —Chest and abdominal Xray (according to urgency) —Ultrasound —CT scan (CT angiography) —MRI — C:\Users\Kubenstein\Desktop\m_1452256670.jpg C:\Users\Kubenstein\Desktop\1419096949.png C:\Users\Kubenstein\Desktop\graphic-1.gif C:\Users\Kubenstein\Desktop\13257_2009_Article_1187_Fig1_HTML.jpg Conservative approach —In patients with high mortality risk —No improvement of life-expectancy —Less than 5,5 cm in diameter – observation —Growth less than 1 cm per year —Asymptomatic, „small“ aneurysms Genetics —High predisposition in patients who suffer from some form of connective tissue disorder, e.g. — MARFAN SYNDROME — EHLER´S –DANLOS SYNDROME — RELAPSING POLYCHONDRITIS — Characters of past —Marfans syndrome C:\Users\Kubenstein\Desktop\5a81cbc2d030729f008b457d-750-563.jpg Characters of past —Diagnosed with abdominal aorta aneurysm —-treated by Nissen, who wrapped it in celophane — — J C:\Users\Kubenstein\Desktop\albert-einstein-sticking-out-his-tongue.jpg Prophylaxis —STOP SMOKING!!! Damn it! –ESSENTIAL FACTOR —Control your blood pressure —Correct your diet – less fatty food —Consume less alcohol —Regular check-ups with control X ray —More movement SURGERY —Open surgery – in younger patiens — - already ruptured — - symptomatic — - elective —Endovascular repair- older patients — (EVAR) - unfit for open surgery — - feasible for only some types — —In general, there is no significant advantage when comparing open end EVAR technique — C:\Users\Kubenstein\Desktop\Endovasc.jpg — C:\Users\Kubenstein\Desktop\abdominal-aortic-aneurysm-evar-captions_698_690_298_c1.png AORTIC DISSECTION —Injury of inner layer of aorta —Blood flows through deffect into medial layer of aortic wall, creating FALSE LUMEN — — Difference : — — Aortic aneurysms have TRUE LUMEN Classification C:\Users\Kubenstein\Desktop\73a0718f5896fac275d0c96273f80430.jpg — C:\Users\Kubenstein\Desktop\nrdp201653-f1.jpg — C:\Users\Kubenstein\Desktop\aorta-layers.gif Causes —Atherosclerotic plaque rupture —In general similar/same as aneurysm —After trauma —CT – crescent shape in axial plane —Identifiable layering C:\Users\Kubenstein\Desktop\Aortic-Dissection-CT.png SURGERY —Especially in ascending aorta dissection – surgical approach SURGERY —Bentall procedure – graft replacement of ascending aorta, aortic root, with re-implantation of coronary arteries — C:\Users\Kubenstein\Desktop\cohn4_c052f005.png SURGERY —David procedure- valve sparing aortic root replacement C:\Users\Kubenstein\Desktop\Ascending-Thoracic-aortic-aneurysm-web-black-outlinename_2000_c.jpg SURGERY —EVAR technique in descending aorta dissection C:\Users\Kubenstein\Desktop\TEVAR(1000x548) (1).jpg Short opportunity to take a breather J — C:\Users\Kubenstein\Desktop\2ff4bb1270eb2eff7f4a2d2fe0809b22b1b589cf6d2ae1139e6b212ed0bba969.jpg Peripheral arterial disease (PAD) —Narrowing of the peripheral arterial system, usually due to atherosclerosis, worsened by other risk factors (diabetes, smoking, hyperlipidemia, artery spasms, hypertension etc...) — — Clinical presentation —Cramping in feets, legs and calfs —Burning sensations —Numbness in feet and legs —Legs/feet cool to touch —Thick toenails —Worsened healing — CLAUDICATION!!!! —- pain during physical activity, walk — — — — — — — —Patient suffers from pain during walk,and needs a rest. During inactivity, pain dissapear. C:\Users\Kubenstein\Desktop\maxresdefault.jpg — C:\Users\Kubenstein\Desktop\peripheral-arterial-disease-symptoms.jpg CLASSIFICATION — C:\Users\Kubenstein\Desktop\classification-of-arterial-disease-and-invstigations-4-638.jpg Rutherford classification — C:\Users\Kubenstein\Desktop\Rutherford-classification.png DIAGNOSIS —Doppler examination - — — — Angiography - — — — —Ankle-brachial index - C:\Users\Kubenstein\Desktop\hqdefault.jpg C:\Users\Kubenstein\Desktop\c31fa51de117ef26757ce750ffbef2d2.jpg C:\Users\Kubenstein\Desktop\Ankle-Brachial+Index+(ABI).jpg TREATMENT —According to stage: mild to moderate —change of regimen –smoking, compensation of DM —Medication (Aspirin, statins, ACE inhib.) —Walk/exercise with gradual overload – helps to induce angiogenesis, which provides collateral arterial blood flow — — SURGERY —PTA – Percutaneous Transluminal Angioplasty —-better for solitary lesions and narrowings, such as in femoral, popliteal or iliac artery —Atherectomy – atherosclerotic plaque removal from inside the artery-scraping —Vascular bypass – used to circumvent the diseased area – either using VSM, or PTFE (polytetrafluorethylene) or Gora-tex graft —Amputation – if gangrene develops —Thrombectomy, thrombolysis PTA — C:\Users\Kubenstein\Desktop\67879495-doctor-surgery-foot-suture-percutaneous-transluminal-angioplas ty-vascular-bypass-graft-surgery-leg-b.jpg C:\Users\Kubenstein\Desktop\Stent-use-in-a-clogged-artery-1-The-stent-is-inserted-2-The-balloon-is- inflated-3.png Atherectomy – „snow plow with suction“ — — — — — — — —Multiple devices – same effect C:\Users\Kubenstein\Desktop\R62970878_g.jpg Successful recanalisation — C:\Users\Kubenstein\Desktop\atherectomy-27-728.jpg C:\Users\Kubenstein\Desktop\627b08b3d2744628d89f7db4483f931e.jpg Amputation —-definite treatment of gangrene, and chronic ulcers, causing septic complications, especially in lower extremities — — Transcutaneous oxygen measurement – TcPO2 —Non- invasive, objective and realiable method which reflects the saturation of sking and soft-tissues with oxygen. —Helps to objectify ischemia, and to decide whether the extremity (defect) can be healed, or whether amputation should be performed — C:\Users\Kubenstein\Desktop\interpreting-tcpo2-curves-and-results-4-638.jpg — C:\Users\Kubenstein\Desktop\skinnontumorgangrenehamodat.png — C:\Users\Kubenstein\Desktop\image-gangrene-amputated-toe.jpg — C:\Users\Kubenstein\Desktop\maxresdefault (1).jpg — C:\Users\Kubenstein\Desktop\_DSC5401.JPG Vascular bypass – in PAD and in general -surgical procedure, allowing the redirection of blood flow from one place to another, using either prosthetic material grafts, allo-grafts or auto-grafts -there are many possible bypass locations, e.g. - — fem-tib, ax-bifem, aorto-bifem, fem-fem —-mimicking physiological path anatomic —-creating new, unique pathways extra-anatomic FEM- TIB – anatomic or no? — C:\Users\Kubenstein\Desktop\h9991467_001b.jpg AX-BIFEM — C:\Users\Kubenstein\Desktop\axillo-femoral-bypass-sketch.png Aorto-bifem — C:\Users\Kubenstein\Desktop\The-covered-stent-graft-is-deployed-into-the-aorta.png Fem-fem — C:\Users\Kubenstein\Desktop\dea_ch7_f003.png Great saphenous vein C:\Users\Kubenstein\Desktop\324d4b854f090d96447957fd64c40e7d.png — C:\Users\Kubenstein\Desktop\maxresdefault (2).jpg ◦Allo-graft from donor ◦ ◦ ◦ ◦ ◦ ◦ ◦ P PTFE ( polytetrafluorethylene) C:\Users\Kubenstein\Desktop\P102916.jpg C:\Users\Kubenstein\Desktop\tmp51b8e15a76268_Femoral-Artery-Photo.jpg Short break? No break? Coffee? Juice? Cigarette? — C:\Users\Kubenstein\Desktop\life-can-be-cruel_o_2541213.jpg Chronic venous insufficiency - varicose veins —-pooling of blood in veins, straining vein walls —-cause can be found in venous reflux, due to inability of vein valves to work properly — C:\Users\Kubenstein\Desktop\VaricoseVeins_1500x10002.jpg Signs and symptoms: —- varices -swelling -hyperpigmentation - pruritus -ulceration -phlebitis - Chronic venous insufficiency —The reflux (incompetence) of vein valves can occur due to: —Phlebitis - infection of superficial veins, e.g. post-traumatic —Superficial vein thrombosis- this poses little to no danger of pulmonary embolism —Deep-venous thrombosis – blood clot formation in deep venous system, which can result in PE - chronic venous insufficiency is then considered as a part of postthrombotic syndrome —1.Thrombofilic state —2.Trauma VIRCHOW´S TRIADE —3.Imobility DIAGNOSIS —Personal history —Clinical examination —Doppler – ultrasound of venous system — —Rule out heart disease and hypervolemic state first! — C:\Users\Kubenstein\Desktop\varicose-veins-doppler-assesment-8-638.jpg — C:\Users\Kubenstein\Desktop\slide_8.jpg Conservative treatment —Effort to stabilize the condition, and prevent it from worsening -compression stockings -venoprotective medication-Detralex -blood pressure maintenance -elevation of lower extremities C:\Users\Kubenstein\Desktop\compression-stockings-3.jpg Stockings effect — C:\Users\Kubenstein\Desktop\download (2).jpg Surgical therapy —stripping —ligation —sclerotherapy —endovenous (intravascular) thermal ablation Stripping — C:\Users\Kubenstein\Desktop\VEIN-Vein-surgery2.png Ligature — C:\Users\Kubenstein\Desktop\surgical_ligation.jpg Endovenous catether ablation — C:\Users\Kubenstein\Desktop\image00-1.jpg Sclerotherapy — C:\Users\Kubenstein\Desktop\download (3).jpg Deep venous thrombosis – (DVT) —- condition in which blood clot forms in deep venous system of legs (rarely elsewhere) -untreated may pose a huge health risk -source of embolism to lungs, or in paradox embolism can cause stroke (venous thromboembolism- VTE) -many patients remain asymptomatic -more often in women — Deep venous thrombosis — C:\Users\Kubenstein\Desktop\S_0917_deep-vein-thrombosis_M1750168.width-610.jpg Deep venous thrombosis — C:\Users\Kubenstein\Desktop\Deep-vein-thrombosis.jpg Signs —pain —tenderness —swelling/oedema —redness (erythema) —warmth —discoloration —may present also with:chest pain, trouble breathing, palpitation,chest dyscomfort, hemoptysis, tachycardia, tachypnoe, .... — — Causes and risk factors: 1.Virchow´s triade –post surgery state 2.Smoking 3.Gravidity 4.Contraceptives 5.Older age 6.Medication 7.Genetic predisposition and disorders Phlegmasia coerulea dolens —translated as „painful blue oedema“ —form od DVT —caused by extensive block in outflow venous system —can present with sudden onset of severe pain, oedema, cyanosis —sometimes may be a first sign of malignant disease-need further examination —Treatment: cathether directed thrombolysis — C:\Users\Kubenstein\Desktop\800px-PCD2016.jpg Diagnosis of DVT —Clinical presentation, examination, risk factors, labs, doppler ultrasound, venography Examination —Hommans sign – dorsiflexion of foot, eliciting pain – possibly dangerous — —Pratt sign – calf squeeze elicite pain — — -positivity does not confirm the diagnosis -negative result does not rule out DVT C:\Users\Kubenstein\Desktop\chris--pratt-gettyimages-452625304_1350jpg.jpg (Chris) Pratt sign – Squeeze my calf doctor ;) Laboratory and Doppler - essential —D-dimer – fibrin degradation product – concentration gets higher, when blood clot decreases, thanks to fibrinolysis, which is physiological in body —Negative D-dimer concentration – 95% no DVT —Possitive D-dimer concenration – may sign DVT, or other pathological condition — —Doppler + D-dimer – sets positive diagnosis — Therapy of DVT —Anticoagulation – LMWH, fondaparinux,UFH —Stockings, walking, check-ups —IVC filters —Thrombolysis – direct with catether or indirect- intravenous – using streptokinase, alteplaze, or urokinase (thrombolytics ensymes) —Mechanical thrombectomy – especially in acute, and symptomatic — —LMWH – stops growth of blood cloth C:\Users\Kubenstein\Desktop\dt_151215_injection_syringe_stomach_800x600.jpg C:\Users\Kubenstein\Desktop\download (5).jpg Inferior vena cava filters — C:\Users\Kubenstein\Desktop\Clot_Filter_636x320.jpg C:\Users\Kubenstein\Desktop\Greenfield_600x600.png Catether thrombolysis — C:\Users\Kubenstein\Desktop\cross-section-of-muscle-and-varicose-vein-with-blood-clot-catheter-is-i nse.jpg Mechanical thrombectomy — C:\Users\Kubenstein\Desktop\FrankMAgliochetti-Report-_stent_retriever.jpg C:\Users\Kubenstein\Desktop\IMG_20180719_002236.jpg VASCULAR TRAUMA — Examination —Vascular trauma may be intracorporal or extracorporal (visible) —Check vital signs: Airway — Breathing — Circulation – signs of shock —Anamnesis — — — — — — — — —Pros- usually younger, healthy patients C:\Users\Kubenstein\Desktop\vascular-trauma-8-728.jpg Check for signs of arterial injury —Hard signs: pulsatile hemorrhage, significant blood loss, acute ischemia —volume resuscitation, tourniquet if possible, and acute repair —Soft signs: minor hemorrhage, small hematoma, associated injury Aproach to arterial injury —Definitive or damage control therapy —Restore blood perfusion —Open vs endovascular treatment —Stable vs unstable patient — Surgery options — C:\Users\Kubenstein\Desktop\what-are-your-options-n.jpg — — — — — — — —IN STABLE PATIENTS C:\Users\Kubenstein\Desktop\endovascular-management-n.jpg Thoracic vascular injury —-take into consideration: —Clinical presentation —Visible penetration of chest wall —Hemodynamic stability/instability —X-ray, CT, CT-angio finding —Insert chest-tube if needed –chest decompression —Think over procedure in thoracic and abdominal trauma — — C:\Users\Kubenstein\Desktop\chest-tube-insertion_mini.jpg Thoracic vascular injury — — — C:\Users\Kubenstein\Desktop\thoracic-vascular-injuries-n.jpg Chest tube insertion — C:\Users\Kubenstein\Desktop\reic2_c039f011.png — C:\Users\Kubenstein\Desktop\blunt-thoracic-aortic-injury-n.jpg — C:\Users\Kubenstein\Desktop\blunt-thoracic-aortic-injuries-n.jpg — C:\Users\Kubenstein\Desktop\operative-management-of-blunt-thoracic-aortic-injury-n.jpg Abdominal injury —Anamnesis —Clinical presentation —Examination- physical, laboratory —Special: —FAST –focused assessment with sonography for trauma —CT —CT-angio —Revision of abdominal cavity Blunt trauma —stable patient, no deffance musculaire, no drop in laboratory – Hb,Ery, negative FAST — — — — Observation Penetrating abdominal injury —Open revision – ALWAYS!!!! Peripheral vascular trauma — C:\Users\Kubenstein\Desktop\peripheral-vascular-trauma-n.jpg Periferal vascular injury —- open fractures, comminutive fractures, stab wounds, semiamputations, cut wounds, GSW, etc... Examination? —What to do? C:\Users\Kubenstein\Desktop\IMG_20180719_013712.jpg —CASE REPORT J Thank you for your attention!!! Now, run home, save yourselves — C:\Users\Kubenstein\Desktop\lkfqk.jpg