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Renovascular Disease: Acute Occlusive and Ischemic Events

Introduction Acute renovascular ischemia is defined as a sudden interruption of arterial and/or venous renal blood flow; it may involve either partial or complete ischemia of one or both kidneys. In the setting of acute renal ischemia, salvage of a functioning kidney requires a high index of suspicion, rapid diagnosis, and prompt implementation of a definitive treatment plan. Acute renal ischemia can progress rapidly to irretrievable…

Renovascular Disease: Endovascular Treatment

Introduction The endovascular treatment of renovascular disease remains controversial. Despite several adequately powered randomized trials, there is no current evidence to support the broad use and efficacy of renal artery stenting. However, renal revascularization remains a commonly used treatment option for selected patients who have clearly failed adequate medical therapy. Endovascular techniques offer the benefits of decreased morbidity, mortality, patient recovery time, and hospital resource utilization…

Renovascular Disease: Open Surgical Treatment

Introduction Following Goldblatt’s innovative work defining the causal relationship between renovascular disease and hypertension in 1934, the surgical management of renovascular disease evolved through three eras: nephrectomy, open surgical correction, and finally renal artery angioplasty with or without stenting ( Fig. 128.1 ). Each era was met with initial enthusiasm, which was soon tempered by the modest results of each treatment. Nephrectomy is now rarely indicated…

Renovascular Disease: Pathophysiology, Epidemiology, Clinical Presentation, and Medical Management

Introduction Renovascular disease (RVD) encompasses a range of disorders that affect renal artery structure and kidney blood flow. The primary importance of RVD relates to renal hypoperfusion causing hypertension (HTN) and loss of renal excretory function. Both in turn contribute to cardiovascular morbidity, dialysis dependence, and death. The most common pathology and major focus of the present chapter is atherosclerotic renal artery stenosis (RAS), found in…

Thoracic Outlet Syndrome: Venous

Introduction Venous thoracic outlet syndrome (vTOS) is thrombosis or severe stenosis of the subclavian–axillary vein secondary to chronic extrinsic mechanical compression. Most commonly, this stems from acquired anatomic changes in the thoracic outlet including anterior scalene or subclavius muscle hypertrophy or from previous bony trauma to the anterior chest. vTOS is the second most common form of thoracic outlet syndrome (TOS). Paget described the original disease…

Thoracic Outlet Syndrome: Arterial

Arterial complications from subclavian artery compression represent the least common type of thoracic outlet syndrome (TOS) in adults, but they also represent the strongest indication for operative intervention. Arterial manifestations usually follow a progressive course characterized by extrinsic compression, poststenotic dilatation, aneurysmal degeneration, thrombus formation, and secondary embolization. Because arterial TOS is typically associated with anomalous osseous structures, this form of TOS has a more easily…

Thoracic Outlet Syndrome: Neurogenic

The management of neurogenic thoracic outlet syndrome (nTOS) requires a comprehensive, multidisciplinary approach, including a prominent role for surgical treatment in well-selected patients. Establishing the diagnosis can be challenging, and disappointing results of treatment have led some authorities to question the need for surgical management of nTOS, and even to challenge whether the condition actually exists (see Ch. 123 : Thoracic Outlet Syndrome: Pathophysiology and Diagnostic…

Thoracic Outlet Syndrome: Pathophysiology and Diagnostic Evaluation

Introduction Thoracic outlet syndrome (TOS) is a condition resulting from compression of the neurovascular structures traversing the thoracic outlet. The syndrome is divided into three types based on the symptoms and signs of neurovascular compression. Neurogenic TOS (nTOS) results from brachial plexus compression (see Ch. 124 , Thoracic Outlet Syndrome: Neurogenic), venous TOS (vTOS) results from subclavian vein compression (see Ch. 126 , Thoracic Outlet Syndrome:…

Upper Extremity Arterial Disease: Amputation

Upper extremity amputation remains infrequent in today’s vascular surgery practice. Loss of a portion of the arm and hand is usually a devastating and life-altering event, with surgery representing only the beginning of a life full of challenges for these individuals. Rehabilitative, social, financial, and psychological considerations are important and may be different from those patients who have suffered lower extremity loss. Epidemiology In 2005, there…

Upper Extremity Arterial Disease: Medical, Endovascular, and Open Surgical Management

Introduction Upper extremity disease and its management are amongst some of the most complex topics in vascular surgery. Unlike lower extremity disease, which is due to atherosclerosis most of the time, upper extremity arterial disease encompasses a wide variety of etiologies. These disease processes ranges from various autoimmune diseases, such as Takayasu and giant cell arteritis, to thoracic outlet disease, embolic disease, hypothenar syndrome, and atherosclerosis.…

Upper Extremity Arterial Disease: Epidemiology, Etiology, and Diagnostic Evaluation

Upper extremity ischemia accounts for less than 5% of patients presenting for evaluation of limb ischemia, with a vast majority of cases being caused by autoimmune/connective tissue diseases. In contrast to the lower extremity, atherosclerosis is not a major etiology of upper extremity ischemia. According to a Dutch study, only 2.3% of diabetic patients and no nondiabetic patients were found to have abnormal Doppler waveforms in…

Podiatric and Vascular Teams

A podiatrist is a clinician who practices medicine and/or surgery of the human foot and ankle. The scope of practice for podiatrists varies by country and even province (in Canada) or state (in the United States). When paired with vascular surgeons, podiatrists are particularly well-suited to augment the long-term medical, surgical, and functional care of the patient with diabetes and an at-risk limb. The Profession And…

Wound Care

The prevalence of diabetes and obesity has increased significantly, which has led to complications such as stroke, peripheral vascular complications, and chronic nonhealing wounds. , In most medical communities, surgeons are considered the local wound care experts and are expected to manage cases that do not respond to conservative treatments recommended by primary care clinicians. This chapter focuses on the diagnosis and management of chronic wounds…

Diabetic Foot Abnormalities and their Management

Introduction Diabetic foot ulcers (DFUs) are often erroneously thought to be a minor complication of diabetes. Diabetic foot ulcers usually start as an innocuous blister from rubbing on a shoe that is too tight, or at the site of an old callus on the sole of the foot. In reality, diabetic foot ulcers are the start of a cascade of events that contribute to repeated infections,…

General Considerations of Diabetic Foot Ulcers

Introduction Diabetes and its subsequent complications, including diabetic foot disease, is a rapidly growing global health pandemic and a major financial burden on healthcare systems worldwide. The International Diabetes Federation estimated that over 463 million people suffer from diabetes in 2020 and that the total number of people with diabetes is predicted to rise to 578 million by 2030 and to 700 million by 2045. China,…

Lower Extremity Amputations: Operative Techniques and Results

Limb amputation, practiced throughout the centuries, is one of the most effective surgical procedures. With benefits ranging from pain relief to preservation of life, amputation offers a clear path to cure the patient. Despite the importance of a well-executed amputation, the task is often relegated to the least-experienced surgeon on the team. Incorporating deliberation with surgical technique can bring about an outcome that is both pain-free…

Lower Extremity Amputations: Epidemiology, Procedure Selection, and Rehabilitation Outcomes

Introduction Major lower extremity amputations continue to be part of all vascular practices despite the general approach of aggressive limb salvage. Although often viewed as a failure of treatment, a major amputation should be considered a reconstructive and definitive treatment option. The convergence of several important factors, including the increased life expectancy of the general population as well as the epidemics of diabetes and peripheral artery…

Infrainguinal Disease: Endovascular Therapy

Introduction The use of endovascular therapies for the treatment of infrainguinal vascular disease has become a key component of a multimodal approach to manage peripheral arterial disease. The decision to employ an endovascular-first interventional strategy relies on several factors, including clinical presentation, lesion anatomy, patient comorbidities and presence of autologous conduit. Most importantly, endovascular therapy should serve as a complement to other methods of treatment, including…

Infrainguinal Disease: Surgical Treatment

Acknowledgment The illustrations were drawn by Joseph L. Mills, Jr. Lower extremity arterial reconstruction is most commonly performed in patients with moderate to severe limb ischemia due to atherosclerotic peripheral artery disease (PAD). Although the techniques described below may also be applied to patients with traumatic, aneurysmal, and nonatherosclerotic conditions, this chapter focuses exclusively on patients with PAD. Infrainguinal bypass is defined as any major arterial…

Aortoiliac Disease: Endovascular Treatment

Background Progress in endovascular surgery has resulted in a continued shift in the treatment of patients with aortoiliac occlusive disease to less invasive forms of therapy. Early pioneers such as Dotter and Gruntzig developed balloon angioplasty. Subsequent work in stent development by Palmaz gradually improved the treatment of patients with aortoiliac disease. Improvements in technology such as higher resolution imaging, lower profile systems, premounted balloon-expandable stents,…