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Acute Upper Extremity and Catheter-Related Venous Thrombosis

Introduction Acute upper extremity deep venous thrombosis (DVT) characterizes a disease process that ranges from an acutely swollen and painful extremity to one that is asymptomatic. This condition can be classified as either primary or secondary. Primary upper extremity DVT is related to either effort thrombosis (i.e. Paget–Schroetter syndrome – see Ch. 126 , Thoracic Outlet Syndrome: Venous) or an idiopathic cause. Secondary upper extremity DVT…

Acute Lower Extremity Deep Venous Thrombosis: Surgical and Interventional Treatment

Acute deep venous thrombosis (DVT) of the lower extremity represents a disease spectrum ranging from asymptomatic calf vein thrombosis to the painful, blue, swollen limb of phlegmasia cerulea dolens resulting from extensive thrombosis involving the iliofemoral venous segment, thereby obstructing the main venous drainage of the lower extremity. This chapter reviews the evidence evaluating whether post-thrombotic morbidity can be reduced by adopting treatment strategies of thrombus…

Acute Lower Extremity Deep Venous Thrombosis: Presentation, Diagnosis, and Medical Treatment

Introduction Acute thrombosis of the lower extremity deep veins is a significant public health problem affecting more than 350,000 people in the United States each year. Lower extremity deep vein thrombosis (DVT) is associated with a 6% mortality at 30 days and responsible for 100,000 to 300,000 deaths annually. , Its economic impact is substantial; in the United States, the annual cost of DVT was estimated…

Venous Thromboembolic Disease: Mechanical and Pharmacologic Prophylaxis

Between 350,000 and 600,000 people in the United States (US) develop venous thromboembolism (VTE) each year, with at least 100,000 deaths from VTE annually. The incidence of VTE is higher among currently or recently hospitalized patients, the annual cost of treatment of VTE in the US as high as $10 billion. The US Surgeon General recognized deep vein thrombosis (DVT) and pulmonary embolism (PE) as major…

Acute Deep Venous Thrombosis: Epidemiology and Natural History

Acute venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), are the most common preventable causes of hospital death and a source of substantial long-term morbidity. The impact on health is so great that the Surgeon General of the United States issued a “Call to Action” to combat VTE. An understanding of the risk factors and natural history of VTE is essential in…

Infected Arterial Aneurysms

Management of infected arterial aneurysms remains a daunting surgical challenge. These infections can occur in any named vessel and often affect elderly patients with multiple medical comorbidities. Medical treatment alone with culture-directed antibiotics rarely eradicates the infection, and excision of the involved vessel with anatomic or extra-anatomic arterial reconstruction is usually required. Reports of using endovascular stent grafts as the primary treatment or a bridging therapy…

Nonatheromatous Popliteal Artery Disease

Introduction Most lower extremity ischemic symptoms occur in patients with atherosclerotic occlusive disease. Nonatheromatous causes must be considered, however, in the absence of significant atherosclerotic risk factors, especially in younger individuals. The two most common nonatheromatous causes of popliteal artery disease are popliteal artery entrapment syndrome (PAES) and adventitial cystic disease (ACD). These patients can be asymptomatic but clinical symptoms associated with these pathologies range from…

Fibromuscular Dysplasia

Introduction Fibromuscular dysplasia (FMD) is an idiopathic, nonatheromatous, noninflammatory, proliferative disease of the musculature of arterial walls, first described in 1938 as a rare cause of renovascular hypertension with a “string-of-beads” appearance. The pathogenesis is still unknown, but up to 10% of cases are familial. Its principal pathologic form involves primarily the media; it affects long, unbranched segments of medium-sized conduit arteries such as the renal…

Raynaud Phenomenon

Raynaud phenomenon (RP) was first described by Maurice Raynaud (1834–1881) in 1862 when he reported 25 patients with intermittent digital ischemia and recognized the relationship of local cold and emotional stress in the causation of the episodes. RP is an exaggeration of the normal physiologic response and is defined as episodic pallor or cyanosis of the fingers caused by vasoconstriction of small digital arteries or arterioles…

Aneurysms Caused by Connective Tissue Abnormalities

The primary structural proteins of connective tissue are collagen and elastin, which vary in type and amount within each of the body’s tissues; those constitutive of blood vessels are listed in Table 141.1 . A connective tissue disease is a genetic disease in which the primary target is either collagen or elastin protein assembly, disruption of which leads to an inherent predisposition to degeneration, loss of…

Takayasu Arteritis

Introduction Takayasu’s arteritis is an immune arteritis causing inflammation of the aorta, its major branches, and pulmonary arteries. It is predominantly a disease of young women, with onset typically in the second or third decade of life. The disease is more common among Asians, although all ethnicities can be affected. The annual incidence in North America is approximately 2.6 per million people. The first description of…

Thromboangiitis Obliterans

Acknowledgments We sincerely thank Drs. Shigehiko Shionoya and Jeffrey W. Olin, the authors of this chapter in previous editions, for their outstanding work, which has provided invaluable insights into Buerger disease, and Drs. Isinsu Kuzu and Suat Aytac of the Ankara University School of Medicine for their scientific assistance and the provision of pathology and radiology illustrations, and Kanat Akar for algorithm illustrations. Introduction Definition Thromboangiitis…

Vasculitis and Other Uncommon Arteriopathies

Vasculitis refers to a group of inflammatory disorders that result in inflammation and necrosis of blood vessels with subsequent impairment of flow resulting in ischemia and infarction of distal tissues. , Often, vascular surgeons are the first physicians consulted in cases of vasculitis, and vasculitis should be considered in patients with ischemic occlusive disease or aneurysmal disease in the absence of traditional risk factors and in…

Mesenteric Venous Thrombosis

The common definition of mesenteric venous thrombosis (MVT) refers to a single entity involving thrombosis within the superior mesenteric vein with or without extension to the portal or splenic veins. Recovery following resection of infarcted intestine secondary to mesenteric vessel occlusion was first reported by Elliot in 1895. MVT was recognized as an entity distinct from mesenteric arterial occlusion by Warren and Eberhard in 1935. Epidemiology…

Median Arcuate Ligament Syndrome: Pathophysiology, Diagnosis, and Management

Introduction “Compression of the celiac artery by the median arcuate ligament is well-documented.” Stanley and Fry published this statement in 1971 after reviewing “provocative xylose absorption tests” in ten female and five male patients over a 3.5-year period. After transecting the median arcuate ligament in these 15 patients, they concluded that intestinal ischemia was the underlying disorder in median arcuate ligament syndrome (MALS). However, 45 years…

Mesenteric Arterial Dissection

Introduction Spontaneous isolated arterial dissection within the splanchnic circulation without associated aortic dissection or associated connective tissue disorder is a rare entity, but is being reported with increasing frequency. This most likely reflects improved imaging modalities, particularly abdominal computed tomography (CT), and increasing awareness of this condition rather than an increasing prevalence. Spontaneous isolated superior mesenteric artery dissection (SISMAD) was first reported by Bauersfeld in 1947.…

Chronic Mesenteric Ischemia: Epidemiology, Pathophysiology, Clinical Evaluation, and Management

Introduction Clinically significant chronic mesenteric ischemia (CMI) is a relatively uncommon disease that was characterized by G.H Goodman in 1918 as “abdominal angina.” In contemporary practice, the term intestinal angina is used to describe the classic symptom of chronic abdominal pain that occurs after meals that eventually leads to food fear and weight loss, which is the hallmark of CMI. Current estimates indicate that CMI accounts…

Acute Mesenteric Ischemia: Epidemiology, Pathophysiology, Clinical Evaluation, and Management

Acute arterial mesenteric ischemia may be challenging to diagnose and treat, resulting in high rates of mortality despite advances in operative technique and critical care. The first superior mesenteric artery (SMA) embolectomy for acute mesenteric ischemia was reported by Klass in 1951. Over the next two decades several reports demonstrated increasing success with SMA thromboembolectomy and thromboendarterectomy for the treatment of acute embolic occlusion; however mortality…

Renovascular and Aortic Developmental Disorders

Introduction Developmental renal artery and abdominal aortic disease is complex and the underlying pathogenesis in the majority of cases is poorly understood. Nevertheless, certain contributing factors are well recognized and the treatment of most lesions has become better defined in the past few decades. The majority of children will benefit from appropriately planned and performed interventions, either endovascular or open surgical procedures, when undertaken in properly…

Renovascular Disease: Aneurysms and Arteriovenous Fistulae

Renal Artery Aneurysms Epidemiology Few vascular surgeons have extensive experience with the clinical management of renal artery aneurysms. , Autopsy studies have revealed an incidence of 0.01% to 0.09%, which is probably an underestimation because renal artery aneurysms may be small, intrarenal, or not specifically sought. , In two catheter-based arteriographic studies, renal artery aneurysms were documented in 0.73% (7/965) to 0.97% (83/8525) of arteriograms. ,…