Chapter 66 / Vascular Surgery 497
What is WET gangrene?	Moist necrotic tissue with signs of
	infection
What is blue toe syndrome?	Intermittent painful blue toes (or fingers)
	due to microemboli from a proximal
	arterial plaque

LOWER EXTREMITY AMPUTATIONS

What are the indications?	Irreversible tissue ischemia (no hope for
	revascularization bypass) and necrotic
	tissue, severe infection, severe pain with
	no bypassable vessels, or if patient is not
	interested in a bypass procedure
Identify the level of the	1. Above-the-Knee Amputation (AKA)
following amputations:	2.	Below-the-Knee Amputation (BKA)
	3.	Symes amputation
	4.	Transmetatarsal amputation
	5.	Toe amputation

1

2

3

4

5

What is a Ray amputation? Removal of toe and head of metatarsal

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ACUTE ARTERIAL OCCLUSION

What is it?

What are the classic signs/symptoms of acute arterial occlusion?

What is the classic timing of pain with acute arterial occlusion from an embolus?

What is the immediate preoperative management?

What are the sources of emboli?

What is the most common cause of embolus from the heart?

What is the most common site of arterial occlusion by an embolus?

What diagnostic studies are in order?

Acute occlusion of an artery, usually by embolization; other causes include acute thrombosis of an atheromatous lesion, vascular trauma

The “six P’s”: Pain Paralysis Pallor Paresthesia

Polar (some say Poikilothermia—you pick)

Pulselessness

(You must know these!)

Acute onset; the patient can classically tell you exactly when and where it happened

1.Anticoagulate with IV heparin (bolus followed by constant infusion)

2.A-gram

1.Heart—85% (e.g., clot from AFib, clot forming on dead muscle after MI, endocarditis, myxoma)

2.Aneurysms

3.Atheromatous plaque (atheroembolism)

AFib

Common femoral artery (SFA is the most common site of arterial occlusion from atherosclerosis)

1.A-gram

2.ECG (looking for MI, AFib)

3.Echocardiogram ( ) looking for clot, MI, valve vegetation

What is the treatment?

What is a Fogarty?

How is a Fogarty catheter used?

How many mm in diameter is a 12 French Fogarty catheter?

What must be looked for postoperatively after reperfusion of a limb?

What is compartment syndrome?

What are the signs/ symptoms of compartment syndrome?

Chapter 66 / Vascular Surgery 499

Surgical embolectomy via cutdown and Fogarty balloon (bypass is reserved for embolectomy failure)

Fogarty balloon catheter—catheter with a balloon tip that can be inflated with saline; used for embolectomy

Insinuate the catheter with the balloon deflated past the embolus and then inflate the balloon and pull the catheter out; the balloon brings the embolus with it

Simple: To get mm from French measurements, divide the French number by , or 3.14; thus, a 12 French catheter is 12/3 4 mm in diameter

Compartment syndrome, hyperkalemia, renal failure from myoglobinuria, MI

Leg (calf) is separated into compartments by very unyielding fascia; tissue swelling from reperfusion can increase the intracompartmental pressure, resulting in decreased capillary flow, ischemia, and myonecrosis; myonecrosis may occur after the intracompartment pressure reaches only 30 mm Hg

Classic signs include pain, especially after passive flexing/extension of the foot, paralysis, paresthesias, and pallor; pulses are present in most cases because systolic pressure is much higher than

the minimal 30 mm Hg needed for the syndrome!

Can a patient have a pulse	YES!
and compartment syndrome?
How is the diagnosis made?	History/suspicion, compartment pressure
	measurement

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What is the treatment of	Treatment includes opening compartments
compartment syndrome?	via bilateral calf-incision fasciotomies of
	all four compartments in the calf
ABDOMINAL AORTIC ANEURYSMS
What is it also known as?	AAA, or “triple A”
What is it?	Abnormal dilation of the abdominal aorta
	( 1.5–2 normal), forming a true
	aneurysm

What is the male to female	6:1
ratio?
By far, who is at the highest	White males
risk?
What is the common	Believed to be atherosclerotic in 95%
etiology?	of cases; 5% inflammatory
What is the most common	Infrarenal (95%)
site?
What is the incidence?	5% of all adults older than 60 years
	of age
What percentage of patients	20%
with AAA have a peripheral
arterial aneurysm?

What are the risk factors?

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Atherosclerosis, hypertension, smoking, male gender, advanced age, connective tissue disease

What are the symptoms?	Most AAAs are asymptomatic and
	discovered during routine abdominal
	exam by primary care physicians; in
	the remainder, symptoms range from
	vague epigastric discomfort to back and
	abdominal pain
Classically, what do testicular	Retroperitoneal rupture with ureteral
pain and an AAA signify?	stretch and referred pain to the testicle
What are the risk factors for	Increasing aneurysm diameter, COPD,
rupture?	HTN, recent rapid expansion, large
	diameter, hypertension, symptomatic
What are the signs of	Classic triad of ruptured AAA:
rupture?	1. Abdominal pain
	2. Pulsatile abdominal mass
	3. Hypotension

By how much each year do AAAs grow?

Why do larger AAAs rupture more often and grow faster than smaller AAAs?

What is the risk of rupture per year based on AAA diameter size?

What are other risks for rupture?

Where does the aorta bifurcate?

3 mm/year on average (larger AAAs grow faster than smaller AAAs)

Probably because of Laplace’s law (wall tension pressure diameter)

5 cm 4% 5–7 cm 7%7 cm 20%

Hypertension, smoking, COPD

At the level of the umbilicus; therefore, when palpating for an AAA, palpate above the umbilicus and below the xiphoid process

What is the differential	Acute pancreatitis, aortic dissection,
diagnosis?	mesenteric ischemia, MI, perforated
	ulcer, diverticulosis, renal colic, etc.

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What are the diagnostic tests?

What is the limitation of A-gram?

What are the signs of AAA on AXR?

What are the indications for surgical repair of AAA?

What is the treatment?

What is endovascular repair?

Use U/S to follow AAA clinically; other tests involve contrast CT scan and A-gram; A-gram will assess lumen patency and iliac/renal involvement

AAAs often have large mural thrombi, which result in a falsely reduced diameter because only the patent lumen is visualized

Calcification in the aneurysm wall, best seen on lateral projection (a.k.a. “eggshell” calcifications)

AAA 5.5 cm in diameter, if the patient is not an overwhelming high risk for surgery; also, rupture of the AAA, any size AAA with rapid growth, symptoms/ embolization of plaque

1.Prosthetic graft placement, with rewrapping of the native aneurysm adventitia around the prosthetic graft after the thrombus is removed; when rupture is strongly suspected, proceed to immediate laparotomy; there is no time for diagnostic tests!

2. Endovascular repair

Repair of the AAA by femoral catheter placed stents

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Why wrap the graft in the	To reduce the incidence of enterograft
native aorta?	fistula formation
What type of repair should	Aortobi-iliac or aortobifemoral graft
be performed with AAA and	replacement (bifurcated graft)
iliacs severely occluded or
iliac aneurysm(s)?

What is the treatment if the patient has abdominal pain, pulsatile abdominal mass, and hypotension?

Take the patient to the O.R. for emergent AAA repair

What is the treatment if the patient has known AAA and new onset of abdominal pain or back pain?

What is the mortality rate associated with the following types of AAA treatment:

Elective?

Ruptured?

What is the leading cause of postoperative death in a patient undergoing elective AAA treatment?

CT scan:

1.Leak S straight to OR

2.No leak S repair during next elective slot

Good; 4% operative mortality

≈50% operative mortality

Myocardial infarction (MI)

What are the other etiologies of AAA?

What is the mean normal abdominal aortic diameter?

What are the possible operative complications?

Why is colonic ischemia a concern in the repair of AAAs?

Inflammatory (connective tissue diseases), mycotic (a misnomer because most result from bacteria, not fungi)

2 cm

MI, atheroembolism, declamping hypotension, acute renal failure (especially if aneurysm involves the renal arteries), ureteral injury, hemorrhage

Often the IMA is sacrificed during surgery; if the collaterals are not adequate, the patient will have colonic ischemia

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What are the signs of colonic ischemia?

What is the study of choice to diagnose colonic ischemia?

Heme-positive stool, or bright red blood per rectum (BRBPR), diarrhea, abdominal pain

Colonoscopy

When is colonic ischemia	Usually in the first week
seen postoperatively?
What is the treatment of	1.	Resection of necrotic colon
necrotic sigmoid colon from	2.	Hartmann’s pouch or mucous fistula
colonic ischemia?	3.	End colostomy
What is the possible long-	Aortoenteric fistula (fistula between aorta
term complication that often	and duodenum)
presents with both upper
and lower GI bleeding?

What are the other possible postoperative complications?

Erectile dysfunction (sympathetic plexus injury), retrograde ejaculation, aortovenous fistula (to IVC), graft infection, anterior spinal syndrome

What is anterior spinal	Classically:
syndrome?		1.	Paraplegia
		2.	Loss of bladder/bowel control
		3.	Loss of pain/temperature sensation
			below level of involvement
		4.	Sparing of proprioception
Which artery is involved	Artery of Adamkiewicz—supplies the
in anterior spinal cord	anterior spinal cord
syndrome?
What are the most common	1.	Staphylococcus aureus
bacteria involved in aortic	2.	Staphylococcus epidermidis
graft infections?		(usually late)
How is a graft infection with	Perform an extra-anatomic bypass with
an aortoenteric fistula	resection of the graft
treated?

Chapter 66 / Vascular Surgery 505

What is an extra-anatomic Axillofemoral bypass graft—graft not bypass graft? in a normal vascular path; usually,

the graft goes from the axillary artery to the femoral artery and then from one femoral artery to the other (fem-fem bypass)

	h
	r
	f
	'
	0
	2
What is an endovascular	Placement of a stent proximal and distal
repair?	to an AAA through a distant percutaneous
	access (usually through the groin); less
	invasive; long-term results pending
CLASSIC INTRAOP QUESTIONS DURING
AAA REPAIR
Which vein crosses the neck	Renal vein (left)
of the AAA proximally?
What part of the small	Duodenum
bowel crosses in front of
the AAA?
Which large vein runs to the	IMV
left of the AAA?
Which artery comes off the	IMA
middle of the AAA and runs
to the left?