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Aortoiliac Disease: Open Extra-Anatomic Bypass

Direct replacement or bypass procedures for aortoiliac or infrainguinal arterial disease were developed in the 1950s. The procedures discussed in this chapter were generally developed shortly after that as alternatives to more direct procedures. These alternative so-called “extra-anatomic” bypass procedures offered the potential benefit of a less formidable operation than aortofemoral bypass in patients with advanced comorbidities, a less hazardous approach in patients with “hostile abdomen”…

Aortoiliac Disease: Direct Reconstruction

Atherosclerotic disease of the abdominal aorta and iliac arteries is one of the most common therapeutic challenges encountered by vascular surgeons. The British anatomist and surgeon John Hunter first appreciated the implications of aortic bifurcation occlusive disease in the late 1700s. His dissection specimens remain on view at the Hunterian Museum in London and laid the groundwork for Leriche’s later appreciation of the disease process that…

Lower Extremity Arterial Disease: Decision Making and Medical Treatment

Lower extremity peripheral artery disease (PAD) encompasses a diverse and complex set of pathologies with multiple treatment options. As a result, shared decision making between the patient, their family/caregiver, and the provider is critical. Even the definition of PAD has been debated, since presentations can range from asymptomatic to gangrene. For the purposes of research and epidemiology, a commonly accepted modern definition is based on an…

Lower Extremity Arterial Occlusive Disease: Epidemiology and Natural History

Epidemiology of Peripheral Arterial Disease Incidence and Prevalence Peripheral arterial disease (PAD) is defined as chronic, atherosclerotic occlusive disease of the lower extremities. It has become a major global health problem, largely secondary to aging of the world’s population, combined with the growing prevalence of risk factors such as diabetes, smoking, hypertension, and dyslipidemia. The increasing burden of PAD has resulted in mortality, morbidity, and escalating…

Atheromatous Embolization and its Management

Atheromatous embolization is a poorly recognized and underdiagnosed multisystem disorder associated with a high risk of all-cause and cardiovascular mortality. There are a myriad of clinical manifestations that may occur across multiple organ systems, making differential diagnoses broad and diagnosis difficult. Further confounding diagnosis, atheromatous embolization is known by many different names: cholesterol embolization, cholesterol crystal embolization, blue toe syndrome, purple toe syndrome, atheroembolism, and pseudovasculitis.…

Compartment Syndrome and its Management

Introduction Compartment syndrome is a surgical emergency and a recognized complication of several conditions treated by vascular surgeons. Failure to arrive at a timely diagnosis increases the risk of short- and long-term morbidity, including limb loss or permanent disability. Conversely, appropriate recognition and management of a compartment syndrome will optimize the chances of a full recovery. This chapter addresses the pathogenesis, diagnosis, and treatment of compartment…

Acute Limb Ischemia: Surgical and Endovascular Treatment

Acute limb ischemia (ALI) is an emergent vascular condition, wherein a rapid decrease in lower extremity arterial perfusion threatens limb viability. Despite advances in the prompt diagnosis and surgical management of limb ischemia, the reported rates of limb loss with amputation approach 15% of hospitalized patients, with a 15%–20% mortality rate within one year of diagnosis. , The etiologies of ALI, initial clinical evaluation, and medical…

Acute Limb Ischemia: Evaluation, Decision Making, and Medical Treatment

Acute ischemia of the limb represents one of the toughest challenges encountered by vascular specialists. The diagnosis and initial assessment are largely clinical, and diagnostic errors can result in a high price to the patient – amputation or even death. Amputation and death rates remain high despite intervention, which is in contrast to major advances in the treatment of many other vascular diseases. Acute ischemia is…

Brachiocephalic Artery Disease: Endovascular Management

Introduction Brachiocephalic arterial disease presents a complex surgical challenge due to the frequent involvement of other arch vessels, choice of inflow and access, as well as the inherent risks of complex surgery, embolization, and cerebral ischemia. This process may affect the aortic arch and/or its branches, including the innominate, the proximal right subclavian (RSCA) and right common carotid (RCCA), the left common carotid (LCCA) and the…

Brachiocephalic Artery Disease: Surgical Treatment

Introduction The brachiocephalic arteries constitute the aortic arch branches, including the innominate, left common carotid (LCCA), and left subclavian arteries (LSCA), also known as the supra-aortic trunks (SAT) or great vessels. SAT disease is predominantly atherosclerosis with steno-occlusive lesions. Aneurysms, arterial dissection, isolated or extending from the aortic arch, arteriopathies, radiation changes, and traumatic injury can occur. These may lead to upper extremity ischemia such as…

Vertebral Artery Dissection and Other Conditions

The vertebrobasilar system supplies blood to the brain stem, cerebellum, and occipital lobes via paired vertebral arteries. Posterior circulation ischemia is most often related to atherosclerosis involving the vertebrobasilar arteries, but may also be related to other vasculitides. Although vertebrobasilar ischemia (VBI) is less common than ischemic episodes related to internal carotid artery disease, approximately 25% of all ischemic strokes do occur in the posterior brain…

Unusual Carotid Artery Conditions

Introduction While cerebrovascular atherosclerotic disease is the most common pathology encountered by vascular surgeons, there are several other distinct entities that can result in cerebral ischemia, bleeding and death. This chapter discusses the rare clinical presentations and treatments for carotid body tumors, carotid sinus syndrome, intracranial carotid aneurysms, intracranial vascular lesions, carotid kinks and coils, and moyamoya disease. Carotid Body Tumors Carotid body tumors are described…

Carotid Body Tumors

Introduction The carotid body tumor (CBT), first described in 1743 by Von Haller, is the only known pathologic condition of the carotid body. The tumor is extremely rare. In 1971, only about 500 cases had been reported in the literature; doubling to more than 1000 by the early 1980s. Due to the infrequency of this disorder, very little is known about its etiology, clinical, and biologic…

Carotid Artery Aneurysms

Introduction Extracranial carotid artery aneurysms (ECAA) are rare in comparison with atherosclerotic occlusive disease in the same location. ECAA can occur as a result of atherosclerosis, trauma, dissection, local infection, or after carotid endarterectomy (CEA). These aneurysms occur less frequently than aneurysms involving the intracranial carotid arteries and their branches. The reported incidence of incidental intracranial aneurysms discovered in autopsy studies ranges from 0.8% to 18%.…

Cerebrovascular Disease: Carotid Artery Dissection

Introduction Carotid artery dissection (CAD) usually occurs secondary to a tear in the intimal layer disrupting the integrity of the arterial wall, which allows blood to leak and accumulate between arterial wall layers. CAD can occur at any age, but is more common among young adults, accounting for approximately 20% of ischemic strokes in this population. While most carotid dissections are spontaneous or follow a minor…

Endovascular Management of Large Vessel Occlusion in Acute Ischemic Stroke

Abbreviations and Acronyms ASPECTS, Alberta Stroke Program Early CT Score; ASTER, Contact Aspiration vs. Stent Retriever for Successful Revascularization; CAST, Committee on Subspecialty Training; COMPASS, Comparison of Direct Aspiration vs. Stent Retriever as a First Approach; CPSSS, Cincinnati Prehospital Stroke Severity Scale; CSC, Comprehensive Stroke Center; CT, computed tomography; CTA, CT angiography; CTP, CT perfusion; ECASS, European Cooperative Acute Stroke Study; ELVO, emergent large vessel occlusion;…

Carotid Artery Stenting

Introduction The concept of endovascular therapy for treatment of carotid artery stenosis was first proposed in 1977 by Mathias, who reported successful results of carotid artery angioplasty using peripheral arterial angioplasty technology. , Balloon-expandable stents for the treatment of cerebrovascular disease were introduced 10 years later, with successful deployment of carotid artery stents in two patients with aneurysms and stenosis of the distal cervical carotid artery.…

Carotid Endarterectomy

First performed in the 1950s, carotid endarterectomy (CEA) experienced remarkable growth in the 1970s and 1980s after several studies demonstrated that carotid stenosis was an important risk factor for disabling stroke and death, and a randomized multicenter trial published in 1969 showed that carotid surgery reduced the incidence of stroke from symptomatic carotid lesions. However, subsequent experience documented high complication rates, thus compromising the potential benefit…

Cerebrovascular Disease: Decision Making Including Optimal Medical Therapy

Carotid Disease And Stroke The management of symptomatic and asymptomatic carotid disease has been the subject of six randomized controlled trials (RCTs) comparing carotid endarterectomy (CEA) with optimal medical therapy (OMT), whereas 20 RCTs have compared CEA with either carotid angioplasty (CA) or carotid artery stenting (CAS). These 26 RCTs comprise the main evidence base for developing pragmatic decision-making in patients. Decision Making In Symptomatic Patients…

Cerebrovascular Disease: Diagnostic Evaluation

Diagnostic Tools Duplex Ultrasound Duplex ultrasound (DU) refers to two modes of ultrasound, namely B mode that obtains gray-scale imaging, and Doppler that evaluates the velocity and direction of blood flow in the vessel. DU determines the degree of carotid artery stenosis based on gray-scale plaque estimation and Doppler spectral analysis of the peak systolic velocity (PSV) and end-diastolic velocity (EDV) in the common carotid artery…