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Venous Thromboembolic Disease

Venous thromboembolism (VTE), which includes both deep venous thrombosis (DVT) and pulmonary embolism (PE), is very common. Although the etiology of acute venous thrombosis (VT) is defined by Virchow triad of hypercoagulability, stasis, and endothelial injury, it is clearly a multifactorial process influenced by many other conditions. The acute thrombotic process must be managed appropriately to relieve edema and pain, to prevent death from PE, and…

Surgical and Endovascular Management of Vascular Trauma Including Aortic Transection

The origins and development of current vascular surgical trauma care are largely based on experiences from wartime casualties and practice. Care for this segment of the population has always presented challenges for physicians to improve medical and surgical practices. Advances in limb salvage were achieved in the mobile surgical hospitals and vascular specialty centers of the Korean and Vietnam Wars. Arterial repairs and vein bypass grafting…

Aneurysms of the Peripheral Arteries

Peripheral arterial aneurysms are less common than aortic aneurysms, but can cause significant morbidity and occasionally lead to death; however, the most common serious complication is end-organ loss or dysfunction. The peripheral aneurysms discussed in this chapter will be the most common ones, including those of the lower extremity arteries below the inguinal ligament, including the femoral artery, as well as the extracranial carotid arteries, and…

Splanchnic and Renal Artery Aneurysms

Aneurysms of the visceral branches of the abdominal aorta are being recognized with increasing frequency. More than half of the splanchnic and renal artery aneurysms described in the English-language literature have been reported in the past 25 years. Splanchnic aneurysms are approximately threefold more common than renal aneurysms. Both aneurysm types are best addressed individually because of the marked variability in their biologic character and clinical…

Building a Hybrid Operating Suite Including Robotic Capability

One of the fastest-growing developments in interventional cardiovascular medicine is the development of the hybrid suite. These are constructed either in a traditional operating room or catheterization laboratory (“cath lab”) environment, thereby permitting a combination of both open and catheter-based procedures. Although hybrid rooms were developed largely to support vascular surgeons, there has been rapid expansion of hybrid room use into other cardiovascular services. Some rooms…

Laparoscopic Aortic Surgery for Aneurysm and Occlusive Disease: Technique and Results

Introduction Today the vast majority of aortic and iliac vascular procedures can be performed by endovascular techniques, yet there are still some indications where open surgical repair or a less invasive technique is indicated. Some of these procedures can be performed using video endoscopic approaches. Currently two laparoscopic approaches are available for abdominal vascular surgery: total laparoscopic aortic surgery in patients with occlusive disease and hybrid…

Open Surgical and Endovascular Management of Ruptured Abdominal Aortic Aneurysm

A ruptured abdominal aortic aneurysm (AAA) is a relatively common but catastrophic problem that, if untreated, will almost always result in the death of a patient. However, with treatment, which can consist of open surgical repair or endovascular graft exclusion of the ruptured AAA (RAAA), many patients will survive and go on to live out their normal lifespan. This chapter discusses important aspects of the open…

Endovascular Repair of Juxtarenal (Chimney), Infrarenal, and Iliac Artery Aneurysms

In 1991, Parodi and colleagues published a seminal study of patients who underwent abdominal aortic aneurysm (AAA) repair using an intraluminal, stent-anchored polyester prosthetic graft delivered retrograde from the common femoral artery and revolutionized the field of vascular surgery. Although initially considered the preferred modality for patients deemed unfit for open surgery, endovascular aneurysm repair (EVAR) has rapidly evolved as an important alternative, less invasive, and…

Aneurysms of the Aorta and Iliac Arteries

Aneurysms of the abdominal aorta (AAAs) are common; the incidence (the number of new cases) and mortality increased steadily from the 1950s to the late 1990s in the United States and other Western countries. This was attributed to the aging of the population, improved diagnostic methods, and other less certain factors. It is estimated, from large national health screening programs, that 1.1 million Americans have this…

Acute and Chronic Aortic Dissection: Medical Management, Surgical Management, Endovascular Management, and Results

Introduction Aortic dissection was first described in the autopsy of King George II of England in 1761, and later the term “dissecting aneurysm” was coined by Morgagni and Laennec in 1819: “aneurysme dissequant.” It is a life-threatening condition that is challenging to diagnose and one of the most complex clinical conditions encountered by vascular surgeons. An aortic dissection is a tear in the intima of the…

Fenestrated-Branched and Parallel Stent-Grafts for Endovascular Repair of Aortic Arch and Thoracoabdominal Aortic Aneurysms

Introduction Endovascular repair has become the first treatment option in most patients with abdominal and thoracic aortic aneurysms. Prospective randomized studies have shown that endovascular aortic repair (EVAR) is associated with lower morbidity, mortality, blood loss, and earlier recovery compared with open surgical repair. For thoracic aneurysms and dissections, endovascular repair (TEVAR) has been shown to decrease mortality, morbidity, and risk of paraplegia compared with open…

Combined Endovascular and Surgical (Hybrid) Approach to Aortic Arch and Thoracoabdominal Aortic Pathology

A hybrid aortic repair consists of an open surgical bypass to perfuse a single or multiple vessels so that a stent-graft can be deployed across their origin(s) to treat aortic pathology. This combined approach was first used at the University of California, Los Angeles to treat a type IV thoracoabdominal aneurysm in 1999 to minimize the morbidity and mortality of a complete open repair in a…

Endovascular Repair of Thoracic Aortic Aneurysm

Thoracic aortic pathology is one of the leading causes of death in the world in those over the age of 65 and in the United States accounts for more than 11,000 deaths annually. Thoracic aortic aneurysms (TAAs) occur less frequently than abdominal aortic aneurysms. The estimated incidence ranges from 5.6 to 10.4 cases per 100,000. The incidence is difficult to discern because TAAs are relatively silent,…

Descending Thoracic and Thoracoabdominal Aortic Aneurysms: General Principles and Open Surgical Repair

The first reported repairs of descending thoracic aortic aneurysms were published in the early 1950s. The first to successfully perform a thoracoabdominal aortic aneurysm repair were Samuel Etheredge and colleagues in 1955 in Oakland, California. One year later, Michael DeBakey and colleagues performed a true thoracoabdominal repair using a homograft. Subsequently the same group devised an ingenious method of using a Dacron tube graft from the…

Thrombolysis for Arterial and Graft Occlusions: Technique and Results

Thrombolytic therapy is an important modality in the treatment of patients with peripheral arterial and venous thrombosis. Randomized clinical trials have compared thrombolytic therapy with traditional surgical options, thus providing guidelines for patient selection. As a therapeutic intervention, lytic therapy may be the best alternative in certain clinical situations. In many other cases, it is just one aspect of the overall care of patients with thrombotic…

Natural History and Nonoperative Treatment of Chronic Lower Extremity Ischemia

Despite the focus on operative and endovascular interventions in vascular surgery, most patients with chronic lower extremity ischemia do not require surgical intervention. Nonoperative therapy and risk factor modification remain the primary components of management for the majority of patients. Less than 2% of people below 50 years of age suffer from symptoms of intermittent claudication; this increases to 5% in those aged 50 to 70…

Thoracic Outlet Syndrome and Vascular Disease of the Upper Extremity

Introduction To many physicians, the diagnosis and management of thoracic outlet syndrome (TOS) is confusing. Part of the confusion arises because TOS is a term applied to three distinct clinical entities, which may share common anatomical elements yet may present with a variety of symptoms. In addition, there has been lack of agreement as to the defining criteria, the indications for intervention, and the anticipated outcomes.…

Thoracic and Lumbar Sympathectomy: Indications, Technique, and Results

Minimally invasive endoscopic technology has rapidly transformed both thoracic and abdominal surgery, and the field of surgical sympathectomies is no exception. For thoracic sympathectomy, the thoracoscopic procedure is used almost exclusively. Laparoscopic and retroperitoneoscopic techniques have also been developed for ablation of the lumbar sympathetic chain. Because of its relatively less invasive nature, the open technique for lumbar sympathectomy is still performed, but with rapidly decreasing…

Endovascular Repair of Infrapopliteal Arterial Occlusive Disease

Endovascular therapy (EVT) has increasingly become the initial clinical option for treating both claudication and critical limb ischemia (CLI). Similar to the evolution of open bypass surgery, EVT began above the knee and has been progressively extended to the infrapopliteal segment, now even including the pedal and arch vessels. Enthusiasm for infrapopliteal EVT was tempered by poor initial results, but advances in technique, equipment, and patient…

Infrainguinal Endovascular Reconstruction: Technique and Results

Management of infrainguinal arterial occlusive disease continues to move away from open surgery and toward percutaneous procedures, and the number of percutaneous options is growing rapidly. This chapter focuses on standard techniques for arterial access, diagnostic imaging, lesion crossing, and options for treating occlusions and stenoses of the femoropopliteal and tibial circulation. Patient Selection and Preoperative Imaging Infrainguinal occlusive disease can usually be diagnosed by history…