Essentials of Vascular Surgery for the General Surgeon

351 Pages·2015·2.47 MB·English

by  Vivian Gahtan

Essentials of
Vascular Surgery for
the General Surgeon
Vivian Gahtan
Michael J. Costanza
Editors
123
Essentials of Vascular Surgery
for the General Surgeon

Vivian Gahtan (cid:129) Michael J. Costanza
Editors
Essentials of Vascular Surgery
for the General Surgeon
Editors
Vivian Gahtan, MD, FACS Michael J. Costanza, MD, FACS
Chief, Division of Vascular Surgery VA Health Care Network Upstate
and Endovascular Services New York at Syracuse
SUNY Upstate Medical University SUNY Upstate Medical University
Syracuse, NY, USA Manlius , NY , USA
Lead Physician, Vascular Surgery Vascular Surgeon
Department of Veterans Affairs Healthcare Department of Veterans Affairs Healthcare
Network Upstate New York at Syracuse Network Upstate New York at Syracuse
Syracuse, NY, USA Syracuse, NY, USA
ISBN 978-1-4939-1325-1 ISBN 978-1-4939-1326-8 (eBook)
DOI 10.1007/978-1-4939-1326-8
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014950048
© Springer Science+Business Media New York 2015
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Prefa ce
Strictly defi ned, vascular surgery involves performing procedures on blood vessels outside the
heart and brain. Although this defi nition is technically accurate, it only scratches the surface of
vascular surgery in the twenty-fi rst century. Vascular surgeons operate on arterial and venous
disease, repair hemorrhagic injuries, perform endovascular interventions, create vascular
access, and manage diabetic foot infections to name just a few areas of practice. Although
vascular surgery emerged as a subspecialty in the 1980s, this fi eld still plays an important role
in general surgery training and practice. Since fewer than 3,000 board certifi ed vascular sur-
geons practice in the USA, many general surgeons rely on their vascular surgery experience
during residency to treat patients with vascular problems. In a recent review of operative logs
from nearly 5,000 surgeons, the American Board of Surgery found that general surgeons per-
formed 46 % of vascular surgery procedures [1]. Although efforts to increase the number of
vascular surgeons have begun, general surgeons will continue to care for vascular patients
given the rapidly increasing elderly population and the comparatively small number of resi-
dency and fellowship trained vascular surgeons entering the work force each year. Unfortunately,
the training that general surgery residents receive in vascular surgery has become less consis-
tent as vascular practice moves toward endovascular therapy. For many general surgery resi-
dents, the breadth of their case volume in vascular surgery experience has narrowed to dialysis
access, amputation, and varicose vein management.
Therefore, fi nding an appropriate reference book for general surgeons who treat vascular
patients can be challenging. Multi-volume textbooks of vascular surgery provide an extremely
detailed and comprehensive approach to vascular conditions that may not readily translate into
real-world practice. At the other extreme, general surgery textbooks condense vascular surgery
into a few chapters that often lack the technical details and treatment guidelines valued by a
practicing surgeon. This book directly addresses the needs of general surgeons who perform
vascular surgery during residency training, clinical practice, or both. As a clinically oriented
resource this book focuses on the diagnosis and clinical management of vascular conditions
while describing the technical details and pitfalls to avoid when performing common vascular
surgery procedures. Ideally this book will serve as a “one stop” information source that sur-
geons and trainees will turn to as a valuable reference, surgical atlas, and study guide.
The contributing authors have used clear illustrations and evidence based treatment recom-
mendations to create clinically relevant chapters. The fi rst chapter provides an organized
approach to the vascular patient with an emphasis on history, physical exam, risk factors, and
diagnostic options. Most vascular conditions require some form of physiologic study or imag-
ing exam to clarify the diagnosis and assist with treatment planning. Chapter 2 lays the founda-
tion for successful vascular surgery by illustrating common vascular exposures and describing
fundamental technical principles unique to arterial surgery. The rest of the book is organized
into parts on arterial disease, venous disease, vascular trauma, vascular access, and complex
vascular conditions.
The chapters on acute arterial disease outline the management and surgical techniques for
the treatment of acute limb ischemia, compartment syndrome, and diabetic foot infections.
Restoring fl ow to an acutely ischemic limb is one of the defi ning interventions of vascular sur-
gery. In many cases, an expeditious surgical thrombectomy as described in Chap. 3 can be the
v
vi Preface
difference between limb salvage and major amputation. Likewise, compartment syndrome
re presents a limb threatening condition that may require immediate intervention by a general
surgeon. Chapter 4 explains and illustrates the steps involved in a fasciotomy which can be a
limb saving procedure. Diabetic foot infections are included in this part (Chap. 5 ) because of
their tendency to require acute surgical intervention. Failure to recognize and adequately debride
diabetic foot infections when indicated can have devastating local and systemic consequences.
C hronic arterial disease is addressed in chapters on the management of claudication, critical
limb ischemia, and lower extremity amputation. Peripheral arterial disease (PAD) affects tens
of millions of patients and can cause disabling symptoms. Chapter 6 discusses the diagnosis
and risk factors associated with claudication while providing an overview of the medical,
endovascular, and surgical treatment options. Chronic critical limb ischemia can manifest as
ischemic rest pain, non-healing ulcers, or gangrene. Chapter 7 focuses on recognizing critical
limb ischemia and preparing patients for limb salvage which may involve surgical, endovascu-
lar, and medical therapy. In some patients, complete limb preservation is not possible and an
amputation is required. A well performed amputation of the toe, forefoot, or leg can have a
signifi cant impact on a patient’s recovery potential and quality of life. Chapter 8 provides
guidelines for choosing the appropriate level of amputation and gives a detailed description of
several common amputations.
The part on venous disease includes chapters on deep and superfi cial venous thrombosis,
chronic venous insuffi ciency, varicose veins, and inferior vena cava (IVC) fi lter placement.
Acute deep venous thrombosis (DVT) poses an immediate life threatening problem if it becomes
a pulmonary embolism (PE) and a long term disability risk if it causes venous dysfunction.
Chapter 9 discusses the medical, endovascular, and surgical treatment modalities for acute DVT
which are aimed at minimizing the short and long term clinical impact of venous thrombosis.
Rarely, anti-coagulation failure or contraindication warrants placement of an IVC fi lter to
reduce the risk of pulmonary embolism. Chapter 13 outlines the indications and risks associated
with IVC fi lters and describes the technical aspects of placing and retrieving IVC fi lters.
Superfi cial venous thrombosis (SVT) can complicate intravenous access and may become an
important clinical problem with the increasing use of peripherally inserted central catheters
(PICC lines). Chapter 1 0 provides practical guidelines for recognizing and managing
SVT. Chronic venous disease encompasses a wide spectrum of clinical disorders ranging from
spider veins to non-healing venous ulcers. Chapter 1 1 focuses on the pathophysiology and non-
interventional treatment strategies for chronic venous insuffi ciency while Chap. 1 2 describes
various techniques for treatment of varicose veins and superfi cial venous insuffi ciency.
T he part on vascular trauma emphasizes surgical intervention for blood vessel injuries that
occur in the neck, abdomen, and extremity. Modern management of vascular neck trauma
incorporates the injury location, hemodynamic status of the patient, and imaging results.
Chapter 14 describes the surgical approach and technical details involved in repairing arterial
and venous injuries in each anatomic zone of the neck. Abdominal vascular injuries often
prove to be fatal without prompt surgical exposure and effective vascular control. Chapter 1 5
illustrates and explains the maneuvers necessary to isolate, clamp, and repair the major abdom-
inal vessels. Extremity vascular trauma poses an ischemic and hemorrhagic risk which may
require immediate revascularization or temporary stabilization followed by delayed defi nitive
repair. Chapter 1 6 reviews the management of extremity vascular injury including anatomic
exposures, the use of tourniquets and shunts, and revascularization principles.
All surgeons regularly encounter patients with vascular access issues. Nearly half a million
people receive hemodialysis in the USA, and most critically ill patients require some form of
central venous access. Chapter 1 7 provides an overview of venous access options and
describes insertion techniques aimed at maximizing safety and effi ciency. Establishing and
maintaining hemodialysis access can be a challenging undertaking that requires planning,
persistence, and technical skill. Chapter 1 8 illustrates and explains the most common arterio-
venous access procedures while Chap. 1 9 focuses on the recognition and management of
vascular access complications.
Preface vii
The fi nal part covers a wide range of vascular topics that are associated with more c omplicated
clinical issues. These chapters provide a broad overview of the diagnosis and treatment principles
for vascular conditions that usually warrant referral to a vascular specialist. Chapter 2 0 summa-
rizes the most recent data and guidelines for managing patients with carotid, renal, and mesen-
teric stenosis. Chapter 2 1 describes the surgical and endovascular treatment options for aortic
pathology including dissections, aneurysms, and traumatic transections. Non- atherosclerotic
diseases often pose a diagnostic challenge because of their rarity and unusual clinical manifesta-
tions. Chapter 22 provides a well-organized and concise reference for evaluating patients with
hypercoaguable disorders, vasculitis, and other uncommon conditions. All surgeons caring for
vascular patients must be prepared to recognize and treat hemorrhagic and infectious complica-
tions. Chapter 2 3 uses clear treatment algorithms to explain the management of common compli-
cations associated with vascular surgery and endovascular interventions.
Approximately 75 % of general surgery residents plan to pursue fellowship training in one
of a dozen or more clinical areas [2]. Despite this trend toward subspecialization, general sur-
geons still derive benefi t from their training and experience in vascular surgery. The ability to
control bleeding, restore perfusion, establish vascular access, and manage the increasing
nu mber of patients with atherosclerotic and venous disease remain valuable skills for general
surgeons. Practicing surgeons and surgical trainees can now turn to this book as a concise and
clinically oriented information source for vascular surgery.
Syracuse, NY, USA Vivian Gahtan, MD, FACS
Michael J. Costanza, MD, FACS
References
1 . Valentine JR, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and
practice patterns in the United States, 2007–2009: A 10 year update from the American Board of Surgery.
Ann Surg. 2011;254:520–6.
2. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellow-
ships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206:782–8.

Contents
Part I Basics of Vascular Surgery
1 Diagnosis and Imaging ............................................................................................ 3
Ali F. AbuRahma and Patrick A. Stone
2 Surgical and Endovascular Technique and Tools ................................................. 25
Eanas S. Yassa and Jeffrey P. Carpenter
Part II Acute Arterial Disease
3 Peripheral Arterial Thrombosis/Emboli ................................................................ 47
Amy B. Reed and Faisal Aziz
4 Compartment Syndrome ......................................................................................... 55
Col (ret) Mark W. Bowyer
5 Diabetic Foot Infection ............................................................................................ 71
Richard F. Neville, Afsoon D. Roberts, and Gary L. Simon
Part III Chronic Arterial Disease
6 PAD and Claudication ............................................................................................. 85
Hasan Haldun Dosluoglu and Purandath Lall
7 Critical Limb Ischemia ............................................................................................ 101
Michael A. Golden and Brant W. Ullery
8 Lower Extremity Amputations ............................................................................... 119
Jason T. Chiriano and Ahmed M. Abou-Zamzam Jr.
Part IV Venous Disease
9 Deep Venous Thrombosis ........................................................................................ 135
Anthony J. Comerota and Hussein Barayan
10 Superfi cial Thrombophlebitis ................................................................................. 151
Anil Hingorani and Enrico Ascher
11 Chronic Venous Insuffi ciency .................................................................................. 157
Kathleen J. Ozsvath
12 Varicose Veins ........................................................................................................... 167
Jennifer A. Heller
13 Inferior Vena Cava Filters ....................................................................................... 183
Misaki M. Kiguchi and Ellen D. Dillavou
ix