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Novel and Evolving Aortic Endovascular Devices

Introduction Endovascular aortic surgery is nearly ubiquitous in modern vascular practice, and has largely supplanted open surgery for appropriate anatomy across virtually the entire length of the aorta. With medical device companies vying for market share, device innovation has been rapid and there are now multiple commercially available options for both standard thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair (EVAR). While some grafts…

Nonaortic Stents and Stent Grafts

Endovascular therapy has changed the landscape of vascular surgical practice. A major thrust into catheter-based therapy was initiated in 1999 with the US Food and Drug Administration (FDA) approval of endografts for aneurysmorrhaphy. As this important technique became ubiquitous, surgeons began to utilize stents in other vascular beds both for initial therapy and as secondary treatment after failed surgical grafts. Endovascular therapy with stents is now…

Bioengineered Vascular Grafts

Basic Principles Surgical repair or replacement of diseased blood vessels, including aortic reconstruction for aneurysmal disease, bypass of occlusive atherosclerotic lesions, vascular trauma, oncologic vascular reconstruction, and creation of durable arteriovenous access for hemodialysis, remains a mainstay of modern vascular surgery. All of these procedures require implantation of a vascular conduit to replace diseased vessels or to augment normal anatomy. When available, autogenous blood vessels are…

Biologic Grafts

In the field of vascular surgery, the use of surgical bypass is fundamental to the treatment of a wide variety of arterial and venous disorders. In turn, the technical conduct and success of surgical bypass are directly dependent on the conduit used. The ideal conduit should be readily available, easy to handle, resistant to thrombosis and infection, durable, inexpensive, and should have characteristics similar to the…

Prosthetic Grafts

Introduction Arthur Voorhees and colleagues first described the use of a prosthetic graft to bridge arterial defects in 1952. Since then, numerous advances have been made in fabric technologies, and a large variety of prosthetic grafts are currently available on the market. Currently, vascular surgeons use prosthetic grafts for several different indications, including aortic aneurysm repair, arterial bypass in the upper and lower extremities, and dialysis…

Autogenous Grafts (Including Vein Harvest, Surgical and Endoscopic)

Background Autogenous vein remains the conduit of choice for infrainguinal revascularization and has been shown to be superior to alternatives above and below the knee in patients with claudication and chronic limb-threatening ischemia (CLTI). , The first report on the use of autogenous vein for the treatment of arterial occlusive disease came in 1944 by Dr. Dos Santos, who performed a vein patch during a superficial…

Laparoscopic and Robotic Aortic Surgery

Introduction Vascular surgery has evolved with the introduction of endovascular procedures. Minimally invasive laparoscopic techniques have also been developed, with a number of reports describing laparoscopic aortic repair for occlusive and aneurysmal disease. There are no large randomized trials to support laparoscopic aortic repair over open or endovascular surgery for abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD). The lack of trained vascular surgeons with…

Endovascular Therapeutic Technique

Introduction Endovascular intervention has replaced open surgery as the primary treatment option for many vascular diseases. This chapter reviews the basic principles, devices, and techniques of endovascular therapy, including indications, limitations, pitfalls, and complications. Balloon Angioplasty The first percutaneous treatment for peripheral artery disease (PAD) was performed in 1964 by Dotter and Judkins, who described a transluminal technique using progressively larger dilators in the lower extremities.…

Endovascular Diagnostic Technique

Introduction Endovascular therapy has become the mainstay of treatment for numerous vascular diseases and has even become preferable over open intervention in a variety of circumstances. In order to fully harness these therapies, vascular surgeons must be facile with a variety of instruments and techniques used for endovascular access, selective vessel catheterization, image acquisition, and post-processing, as well as with techniques to mitigate complications that can…

Open Surgical Technique

Introduction As trainees and practicing vascular surgeons perform fewer open procedures, it becomes increasingly important to understand and become familiar with the established principles of open surgical technique. With advances in catheter-based technology, endovascular therapy is now the first option in many, if not most, clinical scenarios. However, open vascular surgery has traditionally been the “gold standard” with respect to durability and efficacy. Hybrid procedures which…

Spinal Operative Exposure

Spinal disorders, such as degenerative disc disease and spondylolistheses, are treated with interbody fusion. To accomplish this, the spine can be exposed through anterior, transforaminal, oblique, lateral, and posterior approaches. The vascular surgeon becomes critical, however, to the success of the orthopedist or neurosurgeon for the anterior approach to the spinal column, , which was first described in the 1930s. While there is controversy regarding when…

Upper Extremity Vascular Exposure

Introduction Vascular surgeons who treat thoracic outlet syndrome and perform arteriovenous (AV) access obviously regularly operate in the upper extremities, but expeditious and safe upper extremity exposure is required for the treatment of trauma, complex aortic endograft repair of aortic diseases, and many other conditions. For purposes of planning exposure, it is convenient to divide the relevant upper extremity vessels into three zones ( Fig. 59.1…

Lower Extremity Arterial Exposure

Introduction Operations involving the arteries and veins of the lower extremity are among the most frequently performed open vascular surgical procedures in clinical practice (see Ch. 112 , Infrainguinal Disease: Surgical Treatment). Having good familiarity with both the usual and alternative surgical exposures used in the lower extremity should be part of every vascular surgeon’s repertoire. Typically, exposure is made through linear, vertical incisions placed directly…

Cerebrovascular Exposure

Anatomic Considerations The aortic arch gives off, from right to left, the innominate, the left common carotid, and left subclavian arteries. The innominate artery passes beneath the left innominate vein before it divides into the right subclavian and the right common carotid arteries (CCA). The vertebral arteries come off the subclavian arteries 2 or 3 cm from the arch, but many variations may occur. The left…

Abdominal Vascular Exposures

Exposure of Major Abdominal Arteries Anatomic Considerations The aorta enters the abdomen through the aortic hiatus in the diaphragm at the level of T12 vertebra. It is surrounded at this level by the right and left crura of the diaphragm and runs anterior to the spine. The first two branches off the aorta are the two phrenic arteries, which arise anterolaterally. The celiac axis refers to…

Thoracic and Thoracoabdominal Vascular Exposure

Introduction Surgical exposure of the aorta involves three main segments: the ascending aorta and aortic arch, the descending thoracic aorta, and the abdominal aorta. Depending on the pathology, either one or several of these segments will need exposure simultaneously. This chapter presents the various incisions, techniques, and key elements for exposure of each aortic segment or combinations of segments. Exposure Of The Ascending Aorta And Aortic…

Local Complications: Lymphatic

Introduction Due to the close anatomic association between fine lymph vessels, lymph nodes, and corresponding arteries and veins, the possibility of lymphatic complications should always be considered when proceeding with vascular operations. Although the ability of transected or ligated lymphatics to regenerate and re-establish normal lymphatic transport is remarkable, extremity edema after vascular intervention is one of the most common complications. Injury to the lymphatics is…

Venous Complications

In vascular surgery, venous complications arise from different mechanisms, ranging from traumatic to iatrogenic injury, both directly and indirectly. Complications may present as bleeding and hematoma immediately after venous injury or as occult thrombosis or fistula detected only after many months following the initial procedure. Presentations of venous complications are highly variable and can range from subtle to life-threatening. In general, the greater the severity of…

Local Endovascular Complications and their Management

Introduction Endovascular procedures are often the first intervention for peripheral arterial disease and many other vascular surgical conditions. , Although these are thought to be less invasive and “safer,” endovascular interventions can have unique complications that surgeons and other interventionalists should be aware of and be prepared to expeditiously treat. , These complications can range from minor ones, that can be treated with minimally invasive intervention,…

Local Complications: Aortoenteric Fistula

Introduction Aortoenteric fistula (AEF) is defined as a communication between the aorta and gastrointestinal (GI) tract. AEF is classified as primary or secondary based on the underlying cause leading to the fistula development. Primary AEF is a communication between the native aorta and GI tract; secondary AEF is a communication between a reconstructed aorta (for either aneurysmal or occlusive disease) and the GI tract. Sir Astley…