Arterial disease short note by S.

Wichien (SNG KKU)

Carotid A stenosis Severe of stenosis Mild<50% Mod 50-69% Severe 70-99% Clinical 1.Ocular symptom -Amaurosis fugux :transient monocular blindness :hollenhorst plaque in retina vv :choles emboli 2.Sensory/motor deficit 3.Hi cortical fxn--speech Tx 1.symp carotid stenosis (2nd stroke prevention) Med = ASA, clopidogrel Sx=carotid endarterectomy 1.severe dz--sig than drug alone 2.mod dz--favor than drug alone 3.mild stenosis--no benefit Optimal time -early (<2wk of stroke) : hi mortality 2.asymptomatic carotid stenosis (1stroke prevention) Severe ds (>80%) -sx or endovascular revas :benefit Carotid endarterctomy vs Angioplasty+stent hi-risk pt 1.anatomy factor -hi bifurcate >C2 -low common carotid ,below clavicle -contralat carotid occlusion -restenosis prior endarterctomy -previous neck radiation -contralat laryngeal n palsy -tracheostomy 2.physiology factor ->80yr -LV<30% -NYHA 3-4 -recent MI -severe COPD -ESRD on HD -signi CHF Carotid angioplasty + stenting Unfavor -extensive calcify -long segment >2cm -severe tortuosity -carotid a occlusion Preop--clopidogrel 3d Technic -retrograde transfemoral approach 1.distal embolic protection device-EPD 2.+/-pre dilatation balloon 3.stent 4.post dilatation balloon 5.retrieve EPD C/p -acute carotid stent thrombosis--rare -carotid a dissection Carotid endarterctomy Intraop cerebral mornitoring -awake--rxn command -GA--intraop electroencephalogram or Transcranial power doppler Poor collateral flow -intra arterial carotid shunting Technique -hyperextend+turn to contralat side -incision--oblique ant of SCM -dissect bifurcate--facial v,CN12 :bradycardia---stimulate carotid body :inject 1%xylocain to CB :reverse by atropine iv -heparin 1mg/kg before clamp -vascular clamp 1-ICA 2-ECA,CCA -longitudinal arteriotomy in distal CCA -may temporary shunt--CCA-ICA -patch closed :saphenous vein, PTFE -declamp--ECA --> ICA Eversion technic -transect ICA--remove plaque -no need patch closure -clear visual distal zone C/p Acute iipsilat stroke -emboli(common) -prolong cerebral ischemia -thrombosis Ix--carotid duplex Tx--re explor in acute occlusion Bleeding/hematoma Aw compromise CN palsy--traction inj

Arterial disease short note by S.Wichien (SNG KKU)

Carotid artery stenosis (non atherosclerosis) 1.carotid coil,kink -excess elongate of ICA -women > man -cerebral hypoperfusion :sudden head rotation :flex,extension 2.fibromuscular dysplasia -FMD -medium size artery -focal stenosis/multiple lesion with intervening aneurysmal outpouching 3.carotid a dissection Risk--CNT dz -ehler danlos, marfan, alpha1 antitrypsin def Traumatic dissection -hyperextend neck in blunt -penetrating inj Iatrogenic -catheter -balloon angioplasty Clinical Typical -uni neck pain -headache -ilsilat horner synd -cerebral ischemia Tx 1 Tx of symp pt -med--heparin/warfarin, ASA Intervention --endovascular -recurrent TIA,stroke -fail med 4.carotid a aneurysm -pulsatile neck mass -emboli--neuro symptom -rupture/thrombosis--rare Mycotic aneurysm -syphilis--in the past -s.aures--peritonsillar abscess Tx--endovascular 5.carotid body tumor -3rd brachial arch,neural creast -CB--bifurcate of CCA in adventitia -n=glossopharyngeal -a=ext carotid a -5% = malignancy Shamblin class 1-<5cm,free vv involved 2-intima involve,not encase 3-intramural,encase Tx--sx resection 6.carotid trauma cute carotid a thrombosis -asymptom--anticoagulant -cerebral ischemia--revascularized Carotid a dissection -thromboembolism event -distal ICA--petrous part ICA Pseudoaneurysm -sx -selective coil embolization or covered stent

Arterial disease short note by S.Wichien (SNG KKU)

Aneurysm -dilate of a. greater than 1.5x its normal diameter Classification Shape 1.fusiform -spindle -diffuse dilate 2.saccular Wall constitutent 1.true aneurysm 2.pseudoaneurysm/false aneurysm Etiology 1.dissecting aneurysm 2.mycotic 3.traumatic-catheter,trauma AAA -sx mortal<5% -if >5.5 cm :risk of rupture > mortality Etiology/pathology -progressive loss of elastin -increase metalloprotease activity -sex -link and autosomal recessive -smoking Clinical manifestation -major=asymptomatic -incidental finding:x-ray,u/s,CT -new onset low back pain/abdo pain

-pain from stretching retroperitoneal

-aortocaval/aortoduodenal fistula -lower ext embolization -ureteric obstruction PE -pulsatile mass -femoral/distal pulse -carotid bruit Testing 1.ultrasound -screening modality of choice -follow up 2.CT -gold std for pre-op -thin cut(3mm) c contrast -CTA 3.angiography -more accurate -access renal a,horseshoe kidney, mesenteric ischemia,lower ext claudi 4.MR Preop-evaluation 1.symptom 2.hx of pelvic sx/ XR :in retroperitoneal exposure 3.claudication--iliac occlusive dz 4.LE bypass/femoral procedure 5.CKD, contrast allergy

Mycotic aneurysm 1.stap 2.samonella 3.mycobacterium,pasteurella,candida cause -result of infected emboli :aortic,mitral valve -direct extension of area of infection -higher rupture Tx -PTFE resist infection than dacron -may use ATB impregnated dacron :rifampicin -ATB--3-6mo 1.In-situ reconstruction 2.Extra-anatomical approach -Axillo-bifemoral bypass -stap.aureus,pseudo

Arterial disease short note by S.Wichien (SNG KKU)

AAA EVAR Aortic endografting -smaller procedure -not require ICU -2d hospitalization -1-2 wk to normal -10% require additional intervention -in hi risk,have anatomy suitable, benefit in avoiding laparotomy Benefit -minimal invasive -severe pulmo ds -GI c/p C/p -endoleak--ruptured <0.8% -stent graft iliac limb dysfxn :graft kink :progress of atherosclerotic Tx-thrombolysis, graft thombectomy -graft separation/dislocation -rupture--1-1.5%/yr Tx-open conversion vs endovas.stent Anatomy eligibility Neck length >15mm Neck diameter >18 <32mm Neck angle <60 Neck mural calci<50% circumf Neck lumi throm <50% circumf CIA dia 8-20mm CIA length >20mm EIA dia >7mm Aortic endografting -bilat transverse oblique incision (just below inguinal L) :some--complete percu access -transfemoral access :guidewire -iv heparin 80 u/kg -delivery catheter $ device--L1-2 :1device--rt femoral a :contralat iliac limb--lt femoral a -aortogram :locate renal a :1device--deploy below renal a -contralat iliac limb--deploy -complete angiogram Surveillance--CT scan -1st mo -q 6mo*2yr -q 1 yr Complication -illiac a. inj :rupture,dissection,limb occlusion -renal failure from dye toxicity -endoleak Endoleak classification-20-30% T1-attachment site leak <5% -poor pt selection/ inadequate repair -80%--spon seal in 6 mo T2-lumbar/IMA endoleak 20-30% -most common -50%--spon seal T3-junctional leak -if intraop/early post op :inadequate overlap 2 stent -if late period :fabric tear/ jxn separation Tx--prompt repair T4-transgraft -endograft fabric/ porosity leak Endotension--5% -aneurysm grow up but no leak 2intervention--10-15%/yr -migration -endoleak T2--embolization -open sx conversion

Arterial disease short note by S.Wichien (SNG KKU)

AAA sx Traditional open repair -require 1-day ICU -5-7d hospitalization -2mo to normal -long term complication 5-10% Benefit 1.no recur/delay ruptured 2.assess colon Risk 1.cardiac c/p--MI,arrhythmia -most common morbid -2-6% 2.renal failure -periop hypoT -suprarenal clamp 3.atheromatous embolization No femoral p. -poor anastomosis -graft kinking -clamp inj to iliac a. Present femoral p. -distal emboli 4.ischemic colitis -can check by insert catheter into IMA stump and measure back p., if >40mmhg indicate adequate collateral flow and safe ligate of IMA 5.prosthesis graft infection -1-4% 6.spinal cord ischemia -sacrifice lumbar a.to SC Pre-op -risk f.for open aneurysm repair include MI in 6mo co revascularized, CHF,angina,FEV1<1L,cr>2 Sx 1.open approach -midline abdo incision or lt retroperitoneal approach -retract T.colon superiorly -retract small bowel to rt -expose mesentery -incise peritoneum over aorta from iliac bifurcation,up to lt renal v. -IMV can be safely divided and ligated -distal extent of dissection is determined by extent of aneurysmal involvement of iliac a. -heparin 100 u/kg,3 min later illiac a. are clamped,followed by aorta -open aneurysm longitudinally -back bleeding lumbar vv are oversewn c silk 2-0 -graft is sewn end to end c prolene3-0 -graft flushed c heparinized saline -check femoral p. -check sigmoid colon,if not,would exploration of IMA,reimplant to graft -anticoag is reversed by protamine s. -re-approximate aneurysm sac c polyglactin 2-0 -closed retroperito c polyglactin 2-0 Post-op -f/u 1,6 mo then yearly -CT 3yr to look pseudoaneurysm Complication of prosthetic repair -anastomotic aneurysm :distal anastomosis is common -graft infection -graft thrombosis -aortoenteric fistula :<1%,graft erode to duodenum :massive GI bleeding

Arterial disease short note by S.Wichien (SNG KKU)

PAAA -para-anastomotic aortic aneurysm -0.2-15% -mean interval 8-10 yr True PAAA -inadequate resection -continue degen of vv False PAAA -defect in a.,suture,graft -suture material,type of anastomosis mismatch graft,infect -excessive tension on graft Clinical -asymp--major detect late -abdp.pain,back pain,claudication -pulsatile masd -25%--false aneurysm of femoral a. Surveillance -CT/1yr--4yr after repair AAA,rupture -sudden onset -severe abdo/back pain -mortality 70-77% 1/2-not reach hospital 1/2-sx mortal 50% Rx

-emergent repair -avoid aggressive resuscitation and

infuse fluid or blood only to keep pt stable -HTN accelerate additional bleeding -SBP 70 mmhg c cerebrated pt is tolerate while preparation are made to go to OR OR -prep and draped skin c awake pt -when GA=long midline incision -infrarenal or supraceliac control Supraceliac control -incise lesser omentum -exposure aorta at the diaphragm -blunt dissection c finger -finger insert on neck of aorta and post spine -avoid lt renal v. -when neck isolate,coarctation clamp is placed at supraceliac control -open aorta -control illiac vv -declamping aware intractable hyopT -check colon,feet Complication -venous inj -ureter inj -duodenum inj -multi organs fail

Arterial disease short note by S.Wichien (SNG KKU)

Mesenteric a disease ->60yr, woman 3x Cause -atherosclerotic vascu ds--most com other -mesenteric arteritis -radiation arteritis -cholesterol emboli -polyarteritis nodosa -lupus eryth, kawasaki -fibromuscular dysplasia -heavy smoke,young women+OC (intimal hyperpla of a.) Blood supply to intestine (chronic MI--2/3 of vv involved) 1.celiac a (CA) 2.sup mesenteric a (SMA)--most com 3.inf mesenteric a (IMA) CA-SMA anastomosis -sup/inf pancreaticodudodenal a SMA-IMA anastomosis -Drummon arce -Riolan arce Clinical Acute -abdo pain out of proportion to clinical finding in acute type -sudden onset of abdominal cramp in pt c cardiac/atherosclerosis dz -bloody diarrhea from ischemia -bowel emptying from intes spasm -fever-n/v-abdo distention Chronic -postpandrial abdo.pain, food fearwt loss -abdo angina Non-occlusive -old age c CHF,AMI c cardio shock, hypovolemic, hemorrhagic shock, sepsis,digitalis, pancreatitis, vasoconstrictor (epi) -abdo pain (70%of case) :severe pain :vary in locate,character,intensive lnvest -CBC:hemoconcen,leukocytosis -met acidosis -hyperK,azotemia in late stage -film abdomen(exclude other cause) :finding-adynamic ileus, gasless -duplex u/s--use after sx recon -CTA,MRA Definite dx--gold std :biplanar mesen arteriography :time consuming dx 1.emboli -lodge in SMA at origin of middle colic a (meniscus sign) 2.thrombosis -most proximal SMA -taper off 1-2 cm from it origin Therapeutic role in 2. -transcath thrombolytic tx -little role--require definite sx tx -difficult assess bowel viable 3.chronic occlusion -collateral vv 4.non occlusive -segmental mesen vasospasm -diffuse spasm of intes arcade -normal appear SMA trunk Therapeutic role in 4. -catheter at SMA orifice -vasodilator : papaverine

-meandering mesenteric a
:unnamed retroperi collat vv GI Hormone vasodilate -NO,glucagon,VIP Vasocons -vasopressin Type of mesenteric a occlusive dz 1.acute mesen ishemia A.acute embolic -origin from cardiac--AF/MI B.acute thrombotic -typical origin of MA 2.chronic mesen ischemia A.long atherosclerotic process -2/3 of three main MA B.CA compression synd -median arcuate lig synd -extrinsic compression 3.nonocclusive mesen ischemia -low flow state -normal mesen artery -criticism ill pt + vasopressor Aortic operation -OR--ligate IMA -aortic dissection include MA

Arterial disease short note by S.Wichien (SNG KKU)

Endovascular Tx Acute mesenteric ischemia -cath directed thrombolytic tx -urokinase/recombinant tissue PA -within 12 hr of onset -may lead to delay open revas -should select pt Chronic mesenteric ischemia -balloon dilate/stent placement -hi med comorbid, recurrent dz anastomosis stricture (previous sx) Stent placement -calcify ostial stenosis -hi grade eccentric stenosis -chronic occlusion -sig residual stenosis >30% -dissect after angioplasty -restenosis after PTA Non occlusive MI -selective mesen a catheterization follow by infusion of vasodilator (tolazoline,papaverine) :papaverine 30-60 mg/h -concomitant iv heparin :prevent thrombosis in canulate vv -beware hypoT--cath migrate to aorta -if have sign of continue bowel ische (rebound tender/involunguarding)-Sx -Sx should kept warm :prevent further intes vasoconstrict Clinical results of endovascular -inf success rate -low MM--suit in hi risk pt Surgical repair 1.acute embolic MI -fluid resus/anticoag--heparin/ATB 1goal of sx -restore a.perfusion + remove emboli Procedure -midline incision -lift transverse colon/SMB to RUQ -approach SMA :root of SMB mesentery :beneath pancrease :across jxn of 3rd-4th duodenum -proximal control -transverse arteriotomy -balloon embolectomy catheter -assess intestinal viability :intraoperative iv fluorescin injection +inspection with Wood lamp :Doppler assess of antimesen intes -2nd look procedure +/- in 24-48 hr :reassess bowel viability 2.acute thrombotic MI -usually involve atheroscler vv -typical at prox CA,SMA -requir recons procedure to distal SMA to bypass proximal occlusive lesion saphenous v -graft material of choice -avoid prothetic graft--infection Antegrade bypass--supraceliac aorta Retrograde bypass--infrarenal/iliac artery supraceliac infradiphragmatic aorta -less chance kinking -no atherosclerotic lesion 3.chronic MI -goal--revascu mesen circu + prevent develop bowel infarction -typical--multiple mesen a involve Transaortic endarterectomy -ostial lesion of CA MSA -lateral aortotomy Mesen a bypass -lesion 1-2 cm distal to mesen origin 4.celiac a compression synd Goal -release lig structure compress CA -correct persistent stricture--bypass Extrinsic compress -endovascular--fail/recur -should open sx

Arterial disease short note by S.Wichien (SNG KKU)

Acute limb ischemia doppler sensory weak A V 1 no no audible audible 2a minimal no inaudible audible 2b more mild-mod inaudible audible rest pain,intrinsic muscle 3 profound anes+paralysis inaudible skin bleb 1-viable 2-threatened 2a-marginal 2b-immediate--immediate revascu 3-irreversible Embolism source -heart--most com--AF,MI -aortic a eurysm -paradoxical emboli--patent F.ovale Thrombosis -risk f of atherosclerotic -hypercoagulable stage Tx Medical Tx -if no C/I,should heparin -hypercoagulable w/u if suspicious -prevent propagation of clot -iv fluid -retained foley catheter -cr Endovascular Tx 1.Thrombolysis -1st line in class 1,2a Advantage -reduce endothelial trauma -can small br -gradual thrombolyzedec reperfu.S Absolute CI -CVA(+TIA) in 2m -active bleeding diathesis -<10d GIB -neuro sx/IC trauma 3mo C/p -hemorrhage stroke 1-2% 2.percu.mechanical thrombectomy -class 2b -CI for thrombolysis -use djunct c thrombolysis Surgical Tx 1.Embolectomy -prep abdomen,contralat groin, entire lower ext in field -groin vertical incision -expose CFA and bifurcation -transverse arteriotomy -Fogarty balloon embolectomy cathter -complete angiogram -close artery,fully anticoagulant -Post-op:echo,CTdescend/abdo aorta to seek source of emboli -post revascularized syndrome :hypoT,hyperK,myoglobinuria,RF 2.Preexisting PVD -embolectomy can't pass occlusion -angiogram--for extent of occlude, search inflow/distal outflow :to decide thrombolysis vs bypass 2 option 1.bypass graft thrombectomy -good distal vv -good saphenous v graft 2.catheter-based lytic therapy -t-PA,urokinase -lysis time 12-36hr -once clot dissolved,underlying stenosis are tx c balloon angioplasty, stenting,by pass C/P of revascularization -reperfusion synd -compartment synd--ant comp -ischemic neuropathy -m.necrosis -recurrent thrombosis Recurrent thrombosis -recurrent embolization -inadequate removal -a.inj from thrombectomy cath -m.edema precluding distal flow -hypercoag state -technical problems c graft, arteriotomy closure

Arterial disease short note by S.Wichien (SNG KKU)

Chronic limb ischemia (>2wk) Vascular claudication -walk--cramping,tight pain Disbling claudication -claudication <50-100 m -dec of distance Critical limb -ischemic rest pain -toe p.<30,ankle p.<50 mmhg Rutherford class Grade cat 0 0 asymp,normal stress test 1 1 mild claudication 2 mod claudication 3 severe claudication 2 4 ischemic rest pain 5 minor tissue loss 3 6 major tissue loss extending above TM level TASCII (of femoropopliteal occlusion) A--endovascular Tx -single stenosis <=10cm -single occlude <=5cm B -multi steno/occlude c <=5cm/each -single stenosis <=15cm (not infrageniculate popli a) -absent conti tibial vv for distal bypass -single popliteal stenosis C -multi stenosis/occlude >=15cm -recur after 2 endovascular D--open sx -occlude >20cm, involved popliteal -occlude popliteal+prox trifurcation Site -distal SFA--most common (entrap by adductor hiatus) ABI Rt ABI Higher rt S.P.dorsalis,post tibial/ Higher rt/lt S.P.brachial lt ABI Higher lt S.P.dorsalis,post tibial/ Higher rt/lt S.P.brachial >1 =normal <0.9 = PAD 0.5-0.7 =claudication 0.3-0.5 =rest pain <0.3 =gangrene

Arterial disease short note by S.Wichien (SNG KKU)

Chronic AO endovascular Technical -access site=CFA -traverse lesion with guidewire -under fluoroscope -heparin--prevent pericath thrombosis :80-100 u/kg bolus :1000 u/hr Tx--angioplasty,stent,stent graft, anthrectomy -ASA, plavix 6 wk (if stent) 1.percu translumi balloon angioplasty -severe pain--vv rupture/dissect limit in -longer lesion -infrapopliteal 2.subintimal angioplasty -long segment, heavy calcify, fail intraluminal approach -create subintimal dissection 1,2 c/p -dissection,rupture,emboli,pseudoA restenosis,hematoma,vasospasm, Chronic AO Sx 1.Endarterectomy -use in CFA,PFA -no role in SFA--restenosis -open longitudinal--excised atheroma 2.bypass grafting A.SFA,normal PA>4cm,1 vv to foot -AK femoropopliteal bypass graft -PTFE/saphenous VG B.PA involved -outflow--BK-PA,ATA,PTA,peronel a Patency -length of bypass--long=dec patency -quality of recipient a -extent of run off -quality of conduit--VG (not PTFE infrapopliteaL) 2 technic 1.reversed SVG 2.in situ SVG C/p VG thrombosis -15% in 18mo -duplex scan q 3mo--graft velocity :>300cm/s or <45cm/s -stenosis >50%--should repair Tx -angioplasty/stent -short segment venous interposition Limb swelling Wound infection -prosthesis graft infec--excised 3.amputation -class 3 -critical limb in non ambulate :knee contracture,stroke

3.stent placement IC -residual stenosis s/p PTA >30% -dissection/perforate s/p PTA Self expanding stent Ballon expanding stent DES--drug eluting stent -dec restenosis 4.Stent graft Unsupport stent graft--PTFE Support stent graft--metallic skeletal -more inflam--risk graft thrombosis 3,4 c/p -stent fracture/deformity -cover collateral vv-5.Athrectomy device Laser athrectomy C/p -same PTA

Arterial disease short note by S.Wichien (SNG KKU)

Aortoiliac occlusion Collateral a 1.SMA--IMA--hemorrhoid a--int iliac 2.lumbar a--sup gluteal--int iliac 3.lumbar a--deep circum a--CFA 4.subclavian--sup epigas--inf epi --ext illiac (winslow pw) Classification T1.distal aorta+CIA--5-10% -rare limb threatened symp--collat -leriche syndrome -microembolize--trash foot T2.diffuse abdo aorta+CIA--25% -CIA--above inguinal ligament T3.diffuse above-below inguinal--65% -DM,HT,CVA,ACS -present advanced ischemia -require revascularize TASCll TypeA--very good in endovascu -uni/bilat CIA stenosis -uni/bilat EIA stenosis (<=3cm) TypeB--prefer endovascular -infrarenal aorta stenosis (<=3cm) -uni CIA occlusion -EIA stenosis (3-10cm) not to CFA -uni EIA occlusion TypeC--prefer sx -bilat CIA occlusion -bilat EIA stenosis(3-10cm) not to CFA -uni EIA stenosis to CFA -uni EIA occlusion involve IIA,CFA -heavy calcify uni EIA occlusion TypeD--sx -infrarenal occlusion -diffuse ds--aorta,both iliac -diffuse multi steno-uni CIA,EIA,CFA -uni occlusion CIA+EIA -bilat occlusion EIA -iliac stenosis in AAA :not endograft---should open Aortoilliac endovascular Focal aortic stenosis -self expanding stent or balloon expandable stent -balloon size 12-18 mm -distal aorta+bilat prox iliac lesion :kissing stent--bilat prox iliac stent C/p -back/abdo.pain--impending rupture :stent grant Occlusive of aortic bifurcate -kissing balloon Technique :2 angioplasty balloon :across ostia of CIA -require kissing stent Illiac artery disease PTA -isolate iliac stenosis <4cm Primary stenting -longer iliac lesion -all TASC II C/D -recur stenosis after previous PTA -lesion prone distal emboli after PTA :calcify/ulcerate plaque :plaque w spon dissection Selective stenting -PTA-->inadequate-->stent C/p 1.distal embolization--2-10% Tx -percu cath aspiration -sx embolec--large lesion 2.pseudoaneurysm --0.5% -at puncture site Percu thrombin injection u/s guide ->2cm -c/p--rupture Tx--occlusive balloon--coverd stent -faild--sx

Arterial disease short note by S.Wichien (SNG KKU)

Aortoilliac Sx 1.Aortobifem bypass -80%--relief symptom -10-15%--require outflow recons Approach 1.Long midline 2.Retroperitoneal -lt frank incision -previous abdo sx -less GI disturb,dec 3rd space loss Proximal anastomosis 1.end to end -aortic aneurysm 2.end to side -large aberrant renal a unusual large IMA :poor back flow -occlude bilat EIA :no retrograde flow--not end to end Disadvantage -distal embolization -aortoenteric fistula--difficult coverage Distal anastomosis -retroperitonium to groin -end to side anastomosis -aware declamp hypoT 5.Femorofemoral bypass -unilat occlusion CIA/EIA -rest pain, tissue loss, intractable clau -5yr patency--60-70% -inferior to aortofemoral bypass -not clamp aorta--in multi-comorbid -donor site dz--may steal synd 6.Obturator bypass Can't groin area -groin sepsis--prior prosthesis graft -groin tumor/radiation Procedure -tunnel--anteromedial to distal SFA -awarw obturator a/n -mobilized vascularized m flap cover 7.Thoracofemoral bypass IC 1.multiple prior sx c fail intrarenal aortic recons 2.infected aortic prosthesis Procedure -Lt thoracotomy tunnel 1.lt thorax--post lt kidney--lt inguinal li 2.rt limb--retzius space C/p Early -graft thrombosis--1-3% -retroperi bleeding -groin hematoma -declamped shock -bowel ischemia--2% -embolization -ED -lymph leak/chylous ascites -paraplegia Late -graft thrombosis--most com late c/p -graft infection--1% -anastomosis pseudoaneurysm--sx -aortoenteric fistula -aortourinary fistula

Rule -if PFA can 4mm probe or no.3 fogarty can pass 20 cm =adequate outflow/ not revas
2.Aortic endarterctomy -rarely perform :difficult, hi-EBL/sex dysfxn -pt risk of graft infection -hi early thrombosis/late failure 3.Axillofemoral bypass (+femorofemoral crossover) -extraanatomical bypass -hi comorbid pt -patency < aortobifem -axillary a--below clavicle -CFA bifurcate -6-8 mm PTFE graft -5yr patency--30-80% 4.Iliofemoral bypass -unilat occlusion distal CIA/EIA

Arterial disease short note by S.Wichien (SNG KKU)

Graft Autogenous vein -superior to prosthesis -ipsil/contralat GSV,SSV,arm vein Cryopreserved graft -cadaveric -expensive -more failure -freeze--endo.lost--early thrombosis -role in remove infect prosthesis graft + no VG Human umbilical v -less use than PTFE Prosthetic conduit -AK bypass+no VG--PTFE or dacron Compartment syndrome -prolong ischemia follow by reperfuse -capillary leak fluid into interstitial space in muscle which nondistend fascia -most : anterior compartment in leg Compartment Anterior -ext m.,tibialis ant,EDL,EHL, peroneus tertius -ant tibial a/v -deep peroneal n. Lateral -peroneus longus/brevis -sup peroneal n. Deep posterior -deep flexor m,FDL,tibialis post,FHL, popliteus -post tibial a/v,peroneal a/v

Celiac a compression synd -extrinsic compress/impingement -by median arcuate ligament -chronic MI -young female 20-40 yr -abdo symptom ; non specific -pain localize in upper abdomen

-tibial n.
Superficial posterior -superficial flexor m,soleus, gastrocnemius,plantaris Clinical -excessive pain -pain on passive stretching -sensory loss due to n.compression -numbness in web space of 1st-2nd toe : deep peroneal n.comp. Measure -insert arterial line into compartment -Pressures greater than 45 mmHg usually require operative intervention. Pressures between 30 and 45 mmHg should be carefully evaluated and watched closely.

precipitate by meal
-Rx = release ligament structure+ correct any persist stricture by bypass grafting

Buerger ds -thromboangitis obliteran -cause--unknown -non atherosclerotic -small/medium a,v,n -upper/lower ext -20-50 yr,male,smoke -migratory superficial phlebitis Ix Angiography--4 limb -ds confine distal circu -infrapop/distal BA -segmental/skip lesion -extensive collateral--corkscrew Tx -smoking cessation -sx--minimal role--no target vv