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Anastomotic Aneurysms

Introduction In 1956, Birch et al. reported the first case of anastomotic aneurysm in a patient after prosthetic aortic graft placement. Since then, anastomotic aneurysms have been recognized as an infrequent, although important, late complication of prosthetic arterial reconstruction. Although true native aneurysmal degeneration may occur at an anastomotic site, the majority of anastomotic aneurysms are false because they are composed of a fibrous pseudocapsule rather than…

Graft Infection

Introduction The incidence of infection involving vascular prostheses is relatively low because of routine antibiotic prophylaxis before surgical procedures, refinements in the sterilization and packaging of devices, and careful adherence to aseptic procedural and surgical technique. When infection does occur, detection and definitive therapy of the vascular prosthesis are often delayed, with potentially catastrophic consequences. If it is not recognized or treated promptly, implant failure will…

Graft Thrombosis

Introduction Postoperative graft thrombosis remains a significant clinical challenge in contemporary vascular surgical practice. Whether early or late, graft thrombosis continues to account for significant morbidity, limb loss, and mortality in patients requiring vascular intervention. Historically, at 1 year after infrageniculate bypass graft failure, more than 50% of patients will have undergone major amputations. , Among the remaining patients, ischemic pain at rest or ulceration will…

Systemic Complications: Neurologic

Introduction Nerves are complex in formation, surrounded by Schwann cells as the conductive myelin sheath with a supportive structure of extracellular matrix and vasculature. Smaller nerves are simpler, without such supportive structure, relying on diffusion through the interstitial space to supply their metabolic demands. Interestingly, the oxygen requirement of a mammalian nerve is less than that of other tissues, even with increased metabolism. In other words,…

Systemic Complications: Renal

Acknowledgment This text is supported by a Veterans Affairs Merit Grant. Comprehension of renal anatomy and physiology is necessary to understand the complex changes in renal function that can occur during treatment of vascular disorders. This chapter provides a brief summary of renal function and physiology underlying renal complications in the vascular surgical patient population. Renal Anatomy Renal components include nephrons, collecting ducts, and the microvasculature.…

Systemic Complications: Respiratory

Introduction Perioperative respiratory complications are significant contributors to morbidity and mortality, occurring in a large percentage of surgical patients. Prevention and effective management of respiratory complications are vital to provide quality patient care, improve outcomes, and minimize healthcare costs. Common perioperative pulmonary complications ( Box 45.1 ) include atelectasis, aspiration pneumonitis, pneumonia, bronchospasm, acute respiratory distress syndrome (ARDS), respiratory failure, pulmonary embolism, and pleural effusion. Patients…

Systemic Complications: Cardiac

Introduction The maxim that “it is not the kind of disease the patient has rather the kind of patient that has the disease” is apropos since symptomatic vascular disease frequently occurs in the kind of patient that also has multiple cardiac risk factors. , The underlying cardiac conditions common to this patient population, coupled with the frequent perioperative hemodynamic changes and perturbations of the clotting cascade,…

Thrombolytic Agents

Introduction Embolic and thrombotic events in the arterial and venous systems lead to end-organ malperfusion and dysfunction. In the past, open surgical procedures were used to restore vessel patency and organ function; however, with the advent of thrombolytic agents and endovascular techniques, intravenous thrombolysis (IVT) and catheter-directed thrombolysis (CDT) have become essential components in the contemporary management of acute arterial and venous thromboembolic conditions. Thrombolytic agents…

Antiplatelet Agents

Introduction Platelets are the smallest blood cells in the human body, normally numbering 150–350 × 109/L, and play a central role in the normal homeostatic process of hemostasis and thrombosis. As first described in the 18th century, platelets are involved in nearly all aspects of vascular occlusive disease. This includes the disruption of platelet- and fibrin-rich atherosclerotic plaques, which lead to further platelet aggregation and deposition…

Anticoagulant Therapy

Introduction Arterial and venous thromboses are major causes of morbidity and mortality. Arterial thrombosis is the most common cause of acute myocardial infarction (MI), ischemic stroke, and limb gangrene, whereas deep vein thrombosis can lead to pulmonary embolism, which can be fatal. Most arterial thrombi are superimposed on disrupted atherosclerotic plaque, which exposes thrombogenic material in the plaque core to the blood. This material then triggers…

Disorders of Coagulation: Hypercoagulable States

Introduction As first described by Virchow in 1856, the triad of hypercoagulability, vascular stasis and vascular trauma still remains the critical factors associated with vascular thrombosis. Hypercoagulability causes abnormal thrombosis, which may occur in the venous or arterial circulation, as a consequence of both inherited conditions and/or acquired deficits. Different hypercoagulable states, also known as thrombophilias, may contribute to acute limb, or visceral ischemia, stroke, or…

Disorders of Coagulation: Hemorrhage

Introduction Understanding the complex biology of coagulopathy and hemorrhage is critical to the perioperative management of surgical patients. “Coagulopathy” is a term employed loosely in the literature and in the clinical setting. Coagulation is a physiologic defense mechanism aimed at maintaining the integrity of the circulatory system in the setting of vascular injury. There is a critical balance between coagulation and fibrinolysis aimed at preventing pathologic…

Normal Coagulation

Introduction Vascular endothelial cells, blood, and extravascular tissue maintain blood flow fluidity or produce an integrated response to attenuate blood leakage by localized clotting at the site of vascular injury. The processes of blood coagulation and fibrinolysis are the primary defense systems of the vasculature. The opposing forces of fibrin clot formation and dissolution maintain hemostasis and preserve vascular function and integrity. Procoagulant events that culminate…

Hospital Readmissions in Vascular Surgery

Introduction Healthcare spending in the United States has increased dramatically over the past several decades. As of 2020, the US spends approximately $3.6 trillion annually on healthcare, or over 17% of the nation’s gross domestic product (GDP) ( Fig. 37.1 ). This is projected to reach over $6 trillion (almost 20% of GDP) annually by 2028. This unsustainable spending has driven a keen interest in cost…

Postoperative Management

Introduction Complex postoperative care in vascular patients is multi-dimensional and continues well beyond the patient’s hospital stay. Cardiac risk stratification preoperatively in the vascular surgical patient will help predict the level of intensity of monitoring required for the postoperative period (see Ch. 34, Preoperative Evaluation and Management). A simple revised Cardiac Risk (MACE) rate: if >3 factors are present using the RCRI, invasive hemodynamic monitoring intraoperatively…

Intraoperative Management

It is well recognized that the intraoperative management of the patient is a significant determinant of the postoperative course and overall clinical outcome. In light of the frequent associated comorbidity, advanced age, lack of physiologic reserve, complexity of many therapeutic procedures, and other factors, vascular surgical patients can be particularly challenging to manage intraoperatively. The aim of this chapter is to review the important intraoperative considerations…

Preoperative Evaluation and Management

General Preoperative Risk Assessment Every patient undergoing elective vascular surgery should have a preoperative assessment that includes a thorough history and physical examination focused on cardiovascular risk factors, blood analysis, and electrocardiogram (ECG). A complete blood count should be obtained to screen for the presence of infection, to ensure an adequate red blood cell volume, and to rule out a serious hematologic abnormality. Serum electrolyte concentrations…

The Future of Imaging for Endovascular and Open Surgery

Background Vascular surgery has pioneered the development of various novel, minimally invasive catheter-based endovascular procedures within the confines of the open surgical operating room (OR). Portable image intensifier-based C-arm systems were the original imaging platforms on which catheter-based therapies have evolved in the hands of vascular surgeons. Thus far, the portable C-arm imaging system has been the signature imaging tool in the OR that heralded the…

Intravascular Ultrasound

Introduction Catheter-based endovascular techniques are increasingly being used in vascular surgery, with demand for detailed intraoperative imaging increasing accordingly. Intravascular ultrasound (IVUS) is a catheter-based endoluminal guidance system that was initially utilized in interventional cardiology in the 1980s. Various trials and analyses of IVUS-guided versus angiographic-guided percutaneous coronary intervention (PCI) have concluded that IVUS-guided PCI results in similar or improved outcomes overall. In fact, IVUS has…

Vascular PET/CT and SPECT/CT

Conventional radiological imaging modalities for the assessment of blood vessels have focused on size, irregularity of the vascular lumen, and anatomic changes in adjacent structures. The ability of these morphologic imaging techniques to identify physiologic changes such as active inflammatory processes and plaques at risk for rupture is, however, limited. Molecular imaging has the advantage of enabling noninvasive physiologic assessment of these processes with radionuclides, very…