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Acute Arterial Occlusion

Nontraumatic, acute occlusion of arterial supply to a limb or organ presents with a constellation of symptoms specific to the tissue suddenly deprived of arterial perfusion. Irrespective of the arterial segment involved, this syndrome represents a vascular emergency. Irreversible organ injury may occur within seconds in the case of acute embolic occlusion of a middle cerebral artery or take hours when arterial supply of a lower…

Kawasaki Disease

Kawasaki disease (KD), initially described by Dr. Tomisaku Kawasaki in 1967, is an acute systemic vasculitis of uncertain etiology that predominantly affects infants and young children. The disease has been described worldwide and occurs in all populations. The acute illness is self-limited and is characterized by a nonexudative conjunctivitis, inflammation of the oral mucosa, rash, cervical adenopathy, and findings in the extremities, including swollen hands and…

Thromboangiitis Obliterans (Buerger Disease)

Thromboangiitis obliterans (TAO) describes a segmental, nonatherosclerotic inflammatory disorder that primarily involves the small and medium arteries, veins, and nerves of the extremities. Although TAO was initially thought to be a disease confined exclusively to men, epidemiologic studies demonstrate a growing population of women with the disorder. Also known as Buerger disease, TAO has an extremely strong pathophysiological relationship with tobacco use, usually in the form…

Medium and Small Vessel Vasculitis

Medium vessel vasculitis Polyarteritis Nodosa Polyarteritis nodosa (PAN) is a medium vessel vasculitis affecting the main visceral arteries and their branches. The 2012 International Chapel Hill Consensus Conference (CHCC) defines PAN as a necrotizing arteritis of medium and small arteries without glomerulonephritis or vasculitis in arterioles, capillaries, or venules, and not associated with antineutrophil cytoplasmic antibodies (ANCA). The association of PAN with hepatitis B virus (HBV)…

Large Vessel Vasculitis

Acknowledgment The authors acknowledge Dr. Kathleen Maksimowicz-McKinnon and Dr. Gary S. Hoffman for their contributions to parts of this chapter in an earlier edition of this textbook. Large vessel vasculitis refers to a group of diseases involving inflammation of the aorta and/or its major large artery branches not caused by infection, radiation, or trauma. These diseases may come to the attention of vascular medicine specialists through…

Overview of Vasculitis

The vasculitides are a group of rare diseases linked by the pathological consequences of vascular inflammation, including bleeding, ischemia, and infarction of downstream organs ( Box 39.1 ). However, the clinical spectrum of these diseases is wide ranging and includes a myriad of clinical and pathological findings. Not all disease phenotypes that occur in the vasculitides are due to true “vasculitis” (i.e., inflammation of vascular structures).…

Endovascular Therapy for Abdominal Aortic Aneurysm

The surgical treatment of abdominal aortic aneurysms (AAAs) dates back centuries. Some of the initial approaches involved techniques similar, in some fashion, to modern endovascular techniques. In 1684, Moore reported on the use of large quantities of wire placed intraluminally into the aneurysm sac in order to induce thrombosis of AAA. Later, electrical currents were passed through the wire to further promote thrombosis. A self-expanding endoluminally…

Surgical Treatment of Abdominal Aortic Aneurysms

Abdominal aortic aneurysms (AAAs) remain a leading cause of death in the elderly. In the United States, ruptured AAAs are the 15th leading cause of death overall and the 10th leading cause of death in men older than age 55. AAAs account for more than 5500 hospital deaths in the United States, which likely underestimates their true number because 30% to 50% of all patients with…

Clinical Evaluation of Aortic Aneurysms

The vast majority of aortic aneurysms are asymptomatic, accounting for a much higher disease prevalence than hospitalization and mortality statistics would suggest (see Chapter 35 ). These data underscore the central challenge in aortic aneurysmal disease: a common clinical problem that is silent until rupture and death. Aortic aneurysms typically increase in size slowly over years or decades, with few warning signs. The management of aortic…

Epidemiology and Prognosis of Aortic Aneurysms

Aortic aneurysms result in significant morbidity and mortality, accounting for nearly 10,000 deaths and 69,000 hospital discharges per year in the United States. A wide variety of pathological states are associated with aortic aneurysms, including degenerative diseases, genetic disorders, infections, inflammatory conditions, and trauma. Although aneurysms may affect any part of the aorta from the aortic root to the abdominal aorta, the prognosis and outcome in…

Endovascular Therapy for Aortic Dissection

Acute aortic dissection (AAD) is a precipitous event associated with a wide range of outcomes from uncomplicated to catastrophic. Current endovascular strategies are based on identifying features that portend increased risk of death or other poor outcome, and applying interventional techniques to prevent the life-threatening complications of the dissection. During the last 2 decades, there has been increasing interest in exploring endovascular procedures for management of…

Surgical Therapy for Aortic Dissection

Morgagni described the first cases of aortic dissection in 1773, and Maunoir coined the entity “aortic dissection.” Despite these early reports of thoracic aortic disease, it was not until 1952 that Drs. De Bakey and Cooley first successfully operated on a patient with a descending thoracic aortic aneurysm using a lateral resection. In 1956 De Bakey and Cooley replaced the ascending aorta using cardiopulmonary bypass and…

Pathophysiology, Clinical Evaluation, and Medical Management of Aortic Dissection

Acute aortic dissection is an uncommon but life-threatening emergency that requires prompt diagnosis, rapid triage, and immediate treatment. A unified effort across several international centers over the past 20 years has resulted in the establishment of a detailed, prospective registry that describes the major aspects of the presentation, management, and outcomes of patients with acute aortic dissection. This longitudinal experience has led to important clinical insights…

Carotid Artery Revascularization

The management of carotid artery disease remains a topic of current investigation and vigorous debate regarding optimal treatments. Multiple prospective randomized controlled trials have compared the standard therapies, which include carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical therapy (BMT). In addition, hybrid procedures to treat carotid artery stenosis have been added to the therapeutic armamentarium. This chapter focuses on the evidence base, clinical…

Prevention and Treatment of Stroke

The medical management of stroke encompasses a wide range of therapies that include managing physiological parameters in the acute phase, reducing the extent of acute injury, and preventing recurrent strokes. Ischemic stroke is the most common form of cerebrovascular disease and will be the focus of this chapter. Only a brief mention of primary intracerebral hemorrhage (ICH) with regard to acute management and secondary prevention will…

Clinical Presentation and Diagnosis of Cerebrovascular Disease

Stroke is a common and serious disorder. Each year stroke affects almost 800,000 people in the United States, at least 16 million people globally, and is the second leading cause of death in the world (see Chapter 28 ). The associated high morbidity and mortality of stroke, combined with its high cost for acute and chronic care, provide impetus for improving the diagnosis, acute management, and…

Epidemiology of Cerebrovascular Disease

Overview Stroke is the second leading cause of death worldwide, accounting for 4 million deaths in 2004. Cerebrovascular disease is currently the fifth most common cause of death in the United States behind diseases of the heart, cancer, chronic lower respiratory diseases, and unintentional accidents. On average, every 40 seconds someone in the United States has a stroke and every 4 minutes, someone dies. Stroke is…

Vasculogenic Erectile Dysfunction

The first historical descriptions of erectile dysfunction (ED) date back to Egyptian papyrus, nearly 4000 years ago. Egyptian scholars described two types of ED: a “natural” form in which the man was not capable of performing the sex act and a “supernatural” form rooted in evil charms and spells. Ancient thinkers, such as Hippocrates and Aristotle, also theorized on the etiology of ED. However, the first…

Clinical Evaluation and Treatment of Mesenteric Vascular Disease

Clinical evaluation of possible mesenteric ischemia begins with an appropriate index of suspicion for the diagnosis followed by a careful history and physical examination. The major categories of mesenteric ischemia include chronic mesenteric ischemia (CMI), acute occlusive mesenteric ischemia (AMI), nonocclusive mesenteric ischemia (NOMI), and mesenteric venous thrombosis (MVT) (also see Chapter 25 ). Spontaneous mesenteric artery dissections (SMADs) are infrequent causes of abdominal pain that…

Epidemiology and Pathophysiology of Mesenteric Vascular Disease

Mesenteric vascular disease can be characterized as acute or chronic, symptomatic or asymptomatic. Severe acute intestinal ischemia results from sudden symptomatic reduction in intestinal blood flow of sufficient magnitude to result potentially in intestinal infarction. Acute ischemia of the small bowel, colon, and liver may result from mesenteric arterial occlusion (embolus or thrombosis), mesenteric venous occlusion, and/or nonocclusive processes, particularly vasospasm. Dissections of the superior mesenteric…