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Selective (Supraomohyoid) Neck Dissection, Levels I-III

Video 1.1 Neck Dissection Introduction Neck dissection has been a standard method of removing at-risk or involved cancerous lymph nodes in the head and neck for more than 100 years. Crile first described the radical neck dissection in the early 1900s, but modifications by Bocca and others helped reduce the morbidity associated with lymph node removal, allowing for nerve and structure preservation when oncologically sound. This…

Building an Outpatient Interventional Suite

The United States has the most advanced health technology in the world. At the same time, we have one of the most inefficient health care delivery systems. Most of the technology-driven care is concentrated in hospitals, which are inherently inefficient. In the world of vascular disease management, increasing numbers of patients benefit from endovascular techniques. Most patients are discharged after only a few hours of observation.…

Carotid Sinus Stimulation: Background, Technique, and Future Directions

Hypertension affects more than 65 million people in the United States and is one of the most important risk factors for stroke, heart attack, vascular disease, and death. Cardiovascular risk is estimated to double with each 20 mm Hg increment above 115 mm Hg of systolic blood pressure (SBP). Unfortunately, and despite intensive public health efforts and generally effective pharmacologic therapy, control remains poor, in part because adding more antihypertensive…

Anterior Spine Exposure: Operative Techniques for the Vascular Surgeon

Introduction The optimal approach to thoracic, lumbar, and sacral spine exposure depends upon the pathology to be addressed, the level or levels being treated, the patient's other comorbid factors, and the experience of the operator and other team members conducting the procedure. Newer approaches to manage degenerative spondylosis, neural decompression, metastatic and primary tumors of the spine, traumatic fractures, osteomyelitis, and congenital anomalies can be more…

Lower Extremity Amputation

Overview and Historical Perspective Amputation is thought to be one of the oldest surgical procedures. The earliest artificial limb dates from the Samnite wars of 300 bc . Until the time of Ambroise Paré (1510–1590), the techniques for amputation surgery and amputation level selection were extremely crude. Paré improved the surgical technique of amputation through the use of vascular ligatures and developed guidelines for the selection…

The Wound Care Center and Limb Salvage

Knowledge about the management of wounds is a distinct subspecialty requiring knowledge of both normal and nonhealing wound physiology, products to accelerate wound healing, and new therapies for the treatment of recalcitrant wounds. Many subspecialties—such as vascular surgery, plastic surgery, podiatry, and primary care—share a role in managing wounds in the community. Current literature and research regarding wound healing is often published outside of traditional surgical…

Diabetic Foot Complications: A Primer for Vascular Surgeons

Diabetic foot complications are common, costly, and impactful. The experience of many diabetic programs has demonstrated that multidisciplinary or interdisciplinary management of patients with diabetic foot ulcers (DFUs) can significantly reduce complications and produce outstanding outcomes ; participation in these groups may be one of the most beneficial roles a vascular surgeon may play. Vascular surgeons should therefore have a fundamental understanding of the spectrum of…

Management of Complications After Endovascular Abdominal Aortic Aneurysm Repair

Endovascular abdominal aortic aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) has gained wide acceptance since it was first reported in 1991. Randomized controlled trials have shown decreased short-term morbidity and mortality when compared with open controls. Increasing clinical experience coupled with refinements in device design, such as the development of lower-profile delivery systems and improvements in preoperative imaging for procedure planning and device sizing, have…

Noninfectious Complications in Vascular Surgery

With an increasing number of endovascular interventions replacing open vascular reconstruction, the management of open surgical complications may become less familiar to surgeons currently finishing training. Complications after aortoiliac and peripheral arterial reconstruction often develop and progress rapidly to produce disastrous consequences, including major organ failure or loss of limb or life. These complications may be the result of technical errors, the extent of the pathologic…

Prosthetic Graft Infection

The development of prosthetic biomaterial devices has made it possible to treat conditions that otherwise would have resulted in significant morbidity and mortality. Examples of such clinical conditions include but are not limited to aortic aneurysms, hemodialysis access in patients in whom autologous fistulas are not possible, and infrainguinal bypass for limb ischemia. The advent of prosthetic conduits has also resulted in the problem of prosthetic…

Neointimal Hyperplasia

Nearly all vascular interventions are prone to the development of neointimal hyperplasia because any manipulation of the arterial wall induces endothelial cell injury. Current enthusiasm for less invasive but more locally injurious percutaneous peripheral vascular therapies increases the importance of developing strategies designed to suppress neointimal hyperplasia after such interventions. Arterial injury initiates a cascade of inflammatory events that ultimately results in neointimal hyperplasia and limits…

Hemodialysis and Vascular Access

Introduction Access to the vascular system in order to perform life-sustaining dialysis in the face of renal failure remains an important and challenging clinical scenario for vascular surgeons. The number of individuals requiring vascular access for hemodialysis continues to rise. Up to 16% of the world's population now suffers from chronic kidney disease (CKD), which is defined according to “the presence or absence of kidney damage…

Lymphedema

Lymphedema is an important topic for vascular surgeons for three reasons. First, it is very common. There are hundreds of thousands of lymphedema patients in the United States, and hundreds of millions are affected worldwide. Second, even the best surgeons may have patients who develop lymphedema after operations involving the limbs or trunk. Third, lymphedema may be confused with venous disease or other vascular anomalies that…

Portal Hypertension

Portal hypertension and variceal hemorrhage are important clinical problems in which vascular surgeons may still have a significant interest and concern. New developments have altered the once-familiar approach to this disease, with endoscopic and endovascular approaches having replaced what was once treated predominantly with open surgical procedures. Orthotopic liver transplantation has also become a vital component in treating this disease in appropriately selected patients. For a…

Management of Venous Leg Ulcers

A venous leg ulcer is defined as “an open skin lesion of the leg or foot that occurs in an area of venous hypertension.” Venous ulcers are one of the most common chronic vascular diseases: they are estimated to have a prevalence in the United States of approximately 1%, and the frequency of venous leg ulcers increases with age. Once a venous ulcer occurs, the average…

Etiology and Management of Varicose Veins: Surgery, Endovenous Ablation, and Sclerotherapy

The term chronic venous insufficiency (CVI) encompasses a spectrum of symptoms, such as edema, skin changes, or ulceration, which are attributed to functional abnormalities of the venous system and, in turn, venous hypertension. Varicose veins alone are not considered evidence of CVI unless they are associated with other symptoms. CVI is a common problem, affecting more than 2 million patients in the United States. There are…

Endovascular Repair of Chronic Venous Obstruction

Percutaneous endovenous stenting has emerged as a powerful technique for treating chronic venous obstructions. Stenosis and chronic total occlusions (CTOs) are amenable to endovascular correction. The technique is minimally invasive, safe, and effective and does not preclude open correction in case of failure. Endovenous procedures can be applied in geriatric patients and in those who have significant comorbidities that would otherwise preclude open procedures. Intravascular ultrasound…

Surgical Management of Chronic Venous Obstruction

Reconstruction of the occluded iliofemoral vein or the inferior vena cava (IVC) may be required in patients with postthrombotic venous occlusion if they exhibit signs and symptoms of advanced chronic venous insufficiency (CVI). Reconstruction of large veins may also be needed in patients with traumatic or iatrogenic venous injuries or in those who undergo excision of primary or metastatic malignant tumors invading the IVC or the…

Thrombolysis and Mechanical Thrombectomy for Deep Venous Thrombosis and Pulmonary Embolism

Introduction Thrombolytic therapy for venous thromboembolism is an increasingly important option for the management of patients with extensive venous thromboembolic disease, namely iliofemoral venous thrombosis and pulmonary embolism (PE), which alter venous and cardiopulmonary hemodynamics and cause pathologic myocardial stretch or cellular damage. This chapter addresses those patients. Specifically, in patients with deep venous thrombosis (DVT), iliofemoral DVT (IFDVT) is associated with the most severe acute…