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    Emergency in Vascular Surgery

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    steven andrean
    1) The document discusses various vascular emergencies including trauma, acute limb ischemia, aortic aneurysm, varicose veins, and deep vein thrombosis. 2) For vascular trauma and acute limb ischemia, early recognition and treatment within 6 hours is important to minimize ischemic damage and risk of amputation. 3) Diagnosis involves history, physical exam, and imaging tests. Management depends on the condition but may include medications, endovascular procedures, open surgery, and lifestyle changes like smoking cessation.

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    Emergency in Vascular Surgery

    Uploaded by

    steven andrean
    96 views74 pages
    1) The document discusses various vascular emergencies including trauma, acute limb ischemia, aortic aneurysm, varicose veins, and deep vein thrombosis. 2) For vascular trauma and acute limb ischemia, early recognition and treatment within 6 hours is important to minimize ischemic damage and risk of amputation. 3) Diagnosis involves history, physical exam, and imaging tests. Management depends on the condition but may include medications, endovascular procedures, open surgery, and lifestyle changes like smoking cessation.

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    1) The document discusses various vascular emergencies including trauma, acute limb ischemia, aortic aneurysm, varicose veins, and deep vein thrombosis. 2) For vascular trauma and acute limb ischemia, early recognition and treatment within 6 hours is important to minimize ischemic damage and risk of amputation. 3) Diagnosis involves history, physical exam, and imaging tests. Management depends on the condition but may include medications, endovascular procedures, open surgery, and lifestyle changes like smoking cessation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    96 views74 pages

    Emergency in Vascular Surgery

    Uploaded by

    steven andrean
    1) The document discusses various vascular emergencies including trauma, acute limb ischemia, aortic aneurysm, varicose veins, and deep vein thrombosis. 2) For vascular trauma and acute limb ischemia, early recognition and treatment within 6 hours is important to minimize ischemic damage and risk of amputation. 3) Diagnosis involves history, physical exam, and imaging tests. Management depends on the condition but may include medications, endovascular procedures, open surgery, and lifestyle changes like smoking cessation.

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    EMERGENCY IN

    VASCULAR
    SURGERY
    HENRY SINTORO
    BAGIAN BEDAH TORAKS KARDIAK dan VASKULAR
    Fakultas Kedokteran Universitas Hang Tuah
    S U R A B A Y A 2018
    VASCULAR EMERGENCY

    TRAUMA
    VASCULAR TRAUMA

    • Trauma vaskular perifer  3% dari slrh trauma


    • Disebabkan akibat kecelakaan lalulintas maupun kekerasan
    • Trauma vaskular perifer  80% dari trauma vaskular dan 2/3
    kasus mengenai ekstremitas bawah
    • Risiko amputasi sangat tinggi pada grade IIIC
    • Delayed amputation setelah sukses awal  27-70%
    Endothelial Cell
    PROBLEM: REGIONAL ISCHEMIA
    OXYGEN DELIVERY ≠ METABOLIC NEED

    The vulnerability of a tissue to ischemia depends on


    the basal energy requirements & metabolic substrate
    stores (Mattox 2000)
    PERIPHERAL NERVES:
    EXTREMELY VULNERABLE
    High basal energy requirements
    No glycogen stores

    Short periode of ishemic neural damage

    Neuropathic symptoms (paresthesia)
    Neuropathic sign ( loss of light touch sensation)
    1st SIGN OF ARTERIAL INJURY
    SKELETAL MUSCLE:
    RELATIVELY TOLERANT

    • Malan & Tattoni (1963):


    <4h : no histologic changes
    >6h : changes, could be reversed with reperfusion

    • Sanderson et al (1975):
    after 6 h: significant histologic changes that not be
    reversed with reperfusion
    • Cambria et al (1991), Colburn et al (1992), Jerome et al
    (1993):
    Complete interuption of all arterial inflow (including
    collaterals) will result in ischemic damage after 3 hours
    that can be extended (rather than reversed) by
    reperfusion

    REPERFUSION INJURY
    REPERFUSION INJURY
    • Generation of SUPEROXIDE ANION

    Vasoconstriction & Capillaries occlusion

    NO REFLOW PHENOMENON

    • LIPID PEROXIDATION
    • Platelet agregation
    • Microvascular obstruction (neutrophil activation)
    DELAY : increase the risk of
    irreversible ischemic injury,
    organ failure, and death
    EARLY RECOGNITION AND TREATMENT

    GOAL: reperfusion of the ischemic


    limb within 6 hour or less
    PROBLEMS
    • EARLY RECOGNITION / DIAGNOSIS
    • QUICK MANAGEMENT
    • QUICK DIAGNOSIS
    • QUICK OPERATION

    • LIMB SALVAGE OR LIMB AMPUTATION ?


    • RECOGNITION OF TREATMENT FAILURE

    (TIME, DIAGNOSTIC PROCEDURE)


    • MONEY, COST-EFFECTIVENESS
    HARD SIGNS
    • Pulsatile bleeding
    • Expanding hematoma
    • Palpable thrill
    • Audible bruit
    • Evidence of regional ischemia:
     Pallor
     Paresthesia
     Paralysis
     Pain
     Pulselessness
     Poikilothermia
    SOFT SIGNS

    • History of moderate hemorrhage


    • Injury (fracture, dislocation, or penetrating wound) in proximity to major artery
    • Diminished but palpable pulse
    • Peripheral nerve deficit
    (Mattox (2000))
    VASCULAR TRAUMA

    • Tujuan penanganan trauma vascular selama golden


    period 6 jam pertama  mengembalikan perfusi
    demi outcome fungsional lebih optimal.

    • Iskemia hangat < 4 jam (warm ischemia) tidak akan


    menimbulkan nekrosis otot, sebaliknya penundaan > 6
    jam kerusakan otot yang bermakna.
    PROBLEMS TO ARTERY: ACUTE LIMB ISCHEMIA

    • Non Trauma
    VASCULAR EMERGENCY

    NON TRAUMA
    WHEN IS IT CALLED ACUTE?
    ACUTE ISCHEMIC SIGNS
    6Ps=
    • Pain
    • Pale
    • Paresthesia
    • Pulsenessness
    • Paralysis
    BLUE TOE SYNDROME
    • Prostration

    Acute Limb Ischemia.


    Note the discoloration
    of the toes
    ACUTE LIMB ISCHEMIA
    CATEGORIES OF ACUTE ISCHEMIA
    DIAGNOSIS
    Dorsal artery pulse Radial artery pulse
    • History
    • Physical exam:
    • Evaluation of pulse
    • ABPI
    • Diagnostic studies
    • Pulse oxymetri
    • Doppler Ultrasound
    • MSCT angiography
    • arteriography
    Arteriography

    MSCT Angiography

    Ultrasound
    MANAGEMENT
    • Risk factor modification
    • Medication
    • Surgery
    • Endovascular
    • Thrombectomy
    • Open
    • Bypass
    • Interposition
    • Graft

    Bypass graft using PTFE


     Interposition  Bypass

    • Patch
    THROMBECTOMY?
    • In the 1960s & 1970s, balloon catheter
    thrombectomy, first introduced by Fogarty
    cornerstone of therapy.

    • Designed for the retrieval of soft embolus


    and thrombus,  advantage of being
    guidewire compatible allowing radiological
    guidance through occluded, tortuous or
    stenotic arteries.
    Use of Fogarty catheter for embolectomy. Note that withdrawal is parallel to the
    artery
    THROMBOANGIITIS OBLITERANS/TAO/
    BUERGER’S DISEASE
    VON WINIWARTER-BUERGER SYNDROME
    • Definition: a chronic, inflammatory,
    Necrosis of fingers
    thrombotic, nonatherosclerotic,
    segmental, obliterative, tobacco-
    associated vasculopathy
    • Clinical manifestation: distal ischemia
    in male predominant, heavy smoker, Ischemic uleration of toe
    before age 45
    • Diagnosis: clinically, diagnosis criterias
    • Management: smoking cessation,
    medical (antiplatelet, immunomodulation),
    Cardinal sign of TAO=
    surgery for improving flow Superficial thrombophlebitis
    AORTIC ANEURYSM
    • Definition: a focal dilatation of an artery that exceeds the
    normal diameter by at least 50%
    • Patophysiology: collagen degradation, wall stress, inflammation →
    dilatation → risk of rupture, embolism
    • Risk factors:
    • Genetic predisposition

    • Age > 60 years


    • Cigarette smoking
    • Male gender
    • Atherosclerosis
    • Hemodynamic stress
    • Microbial infection
    Abdominal Aortic Aneurysm
    AORTIC ANEURYSM: MANAGEMENT
    Open Repair of AAA
    • Diagnosis:
    • History:
    • abdominal discomfort/pain
    • back pain
    • excruciating tearing pain
    (dissection)
    • pulsatile mass
    • Doppler ultrasound
    • MSCT
    • Management
    • Observation
    (diameter<5.5cm)
    • EVAR, TEVAR
    • Open surgery
    Endo Vascular Aortic Reconstruction
    AORTIC ANEURYSM CLASSIFICATION
    AORTIC DISSECTION CLASSIFICATION
    TREATMENT : EVAR TEVAR VS OPEN
    VARICOSE VEIN
    • Definition: abnormal elongation, dilatation and
    tortuousity of vein segment

    • Etiology: Truncal varises/


    C3 CEAP classification
    • Primary: idiopathic
    • Secondary:
    • post phlebitic
    • Obstruction
    • Venous flow obstruction

    • Congenital: Patophysiology:
    • Klippel-trenaunay
    Incompetence of vein valve →
    reflux → microcirculatory
    syndrome
    disturbance
    Teleangiectasia
    Reticular varices
    CHRONIC VENOUS INSUFFICIENCY (CVI)
    VARICOSE VEIN
    • Anatomy, 3 vein systems: Perforator vein
    connectiong superficial
    1. Superficial vein and deep system
    2. Perforator vein=
    connecting superficial and
    deep system
    1. Deep vein
    • Factors affecting vein 3
    flow
    • Hormonal (contraception)
    • Vis a tergo
    • Vis a front
    1
    1
    • Skeletal muscle pump
    • Valve competence
    • Blood viscosity
    • Degenerative
    VARICOSE VEIN

    • Diagnosis:
    • Physical exam
    • Doppler ultrasound
    • Venography
    • Pletysmography

    • Management
    • Conservative: zinc zalf, compressive bandage
    • Medical: MPFF
    • Foam sclerotherapy
    • Endovenous ablation
    (EVLA, EVRFA)
    • High ligation/ stripping
    • Valve transplantation
    MANAGEMENT OF
    VARICOSE VEIN
    OVERVIEW

    Varicose vein stripping

    Endovenous ablation

    Compressive therapy
    DEEP VEIN THROMBOSIS

    Definition: formation of
    thrombus in the deep vein
    Risk factors:
    • Major trauma
    • Major surgery
    • Immobility
    • Dehydration
    • Prothrombic medications DVT
    • Hyperosmolarity
    • Coagulopathies
    • Venous obstruction Emboli
    • pregnancy
    PATOPHYSIOLOGY OF DVT

    VIRCHOW triad
    3Vs
    • Viscosity
    hypercoagulability
    • Velocity
    stasis
    • Vascular wall problem
    vessel wall injury
    THROMBOSIS
    DEEP VEIN THROMBOSIS

    Symptoms and signs


    • Asymptomatic
    • Hot, tender, swollen
    and tender calf or
    thigh
    • Dilated superficial veins
    • Enlarged calf diameter
    • Homan’s sign
    DEEP VEIN THROMBOSIS

    • Diagnosis
    • History
    • Physical exam
    • Well’s scoring
    • D-dimer
    • Doppler ultrasound:
    non-compressible vein
    + thrombus
    DEEP VEIN THROMBOSIS

    • Management:
    • Anticoagulation
    • Catheter-directed thrombolysis
    • Percutaneous mechanical thrombectomy
    • Open surgical thrombectomy
    • Complications
    • Pulmonary embolism
    • Reccurent thrombosis
    • Post-thrombotic syndrome
    • Pulmonary hypertension
    • Venous ischaemia
    THANK YOU

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