Vascular—Chronic Lower Extremity Ischemia
Concept
Peripheral vascular disease in the extremities that may present in several ways. Often times the examiners here will be testing your knowledge of the indications for surgery and your nonoperative management of PVD.
Way Question May be Asked?
“45 y/o male presents to the office for evaluation of pain in his right thigh and calf after walking 3 blocks. He is a smoker, overweight, and is currently on no medications.”
How to Answer?
Be specific in your indications for surgery:
Rest pain
Non-healing ulcer Gangrene
Intermittent claudication that:
Fails to improve with nonoperative therapies Severe enough to interfere with person’s
lifestyle
History should focus on risk factors:
Smoking DM HTN Overweight
Physical exam should look for signs of vascular disease Document pulses!
Neuro exam
Hairless skin, changes in nails Ankle-Brachial Index
Check for abdominal/femoral bruits
Remember to perform pre-op cardiac work-up
Nonoperative Therapy
Risk reduction (smoking cessation, weight reduction, control of glucose levels and SBP)
Graded exercise program Anti-platelet therapy (Trental)
Non-Invasive Vascular Laboratory
Doppler ultrasound Segmental PVRs
Exercise treadmill testing
Invasive Tests
Aortogram with distal run-off or MR Angiogram
Only take claudicant to surgery after long term follow-up has shown failure of nonoperative therapies and the pt has been committed to risk reduction (smoker doesn’t get bypass!
Operative Approach
Always need adequate inflow and adequate outflow
Isolated aortoiliac lesion is amenable to angioplasty/
stent
Try to use vein if possible (in-situ or reversed SVG)—
assuming pt has not had cardiac surgery—
SVG harvesting (autogenous grafts have best patency rates)—
pre-op duplex will evaluate the suitability of vein and can map location
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If using prosthetic graft, use PTFE
Choice of distal target depends on pre-op arteriography Vertical incision to expose common femoral artery at
groin
Medial approach to expose popliteal above the knee Exposure of peroneal and posterior tibial below trifur-
cation are best exposed by detaching the soleus mus- cle from the tibia
Anterior tibial exposed by a longitudinal incision two fingers-breadths lateral to the anterior tibial border exposing the anterior tibial between the anterior tib- ialis and extensor digitorum longus
For in-situ grafts, valves are incised through side branches using Mills valvulotome
Patency rates for infra-inguinal bypass for disabling claudication:
~70% at 5 years
Completion angiogram in OR Don’t forget to give heparin intra-op
Common Curveballs
Post-op hemorrhage
Post-op graft thrombosis or infection Any stent placed will occlude
Angioplasty performed will restenose
Angioplasty performed will lead to vessel dissection Post-op compartment syndrome will develop Pt will develop heparin induced thrombocytopenia
Strikeouts
Not being clear in your indications for surgery
Not trying nonoperative therapy for the intermittent claudicant
Not knowing your non-invasive vascular studies Not taking pt back to surgery for immediate post-op
graft thrombosis
Trying to describe a technique you don’t do (in-situ SVG)
Not being prepared for postoperative complications Not being able to read angiogram if handed to you Spending lots of time on endovascular techniques.
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