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Endoscopic Harvesting of the Saphenous Vein

Open vein harvest (OVH) for coronary artery bypass grafting (CABG) and infrainguinal bypass procedures is associated with increased patient morbidity and postoperative wound complications. In the limb salvage population, patients exhibit severe peripheral arterial occlusive disease, marginal distal perfusion, poor nutrition, and infected wounds. These factors make it difficult to heal the lower-extremity skin incisions that are required to harvest long, continuous segments of saphenous vein…

Surgical Management of Femoral, Popliteal, and Tibial Arterial Occlusive Disease

This chapter discusses open surgical options for femoral, popliteal, and tibial arterial occlusive disease. Although some of these procedures may also be performed for disabling intermittent claudication, the vast majority should only be performed for critical lower limb ischemia, which is defined as sufficiently poor arterial blood supply to pose a threat to the viability of the lower extremity. Manifestations of critical ischemia are rest pain,…

Angioplasty and Stenting for Mesenteric and Renal Artery Disease

Mesenteric Arterial Disease Chronic mesenteric ischemia (CMI) is an uncommon disorder, accounting for fewer than 1 per 100,000 hospital admissions in the United States. Since the first successful mesenteric endarterectomy by Shaw and Maynard in 1958, techniques of revascularization have evolved. The first endovascular angioplasties for mesenteric stenoses were performed in 1980. Similar to renal artery stenosis (RAS), endovascular approach has become the first line of…

Diagnosis and Management of Renal Vascular Occlusive Disease

Historical Background Renovascular Hypertension In 1934, Goldblatt demonstrated that constriction of the renal artery (renal artery stenosis [RAS]) produced atrophy of the kidney and hypertension in dogs. As a clinical pathologist, Goldblatt noticed that extensive vascular disease was often present at autopsy in patients with hypertension and was frequently severe in the renal arteries. In his own words: “Contrary, therefore, to what I had been taught,…

Diagnosis and Surgical Management of the Visceral Ischemic Syndromes

Although the causal relationship between mesenteric vascular occlusion and intestinal gangrene was suspected in the 15th century, the first successful case of intestinal resection for infarction was not reported until 1895. Recognition of the chronic form soon followed, with the term angina abdominis applied by Goodman to illustrate the similarities to the newly described angina pectoris. Indisputable evidence was provided in 1936 by Dunphy, a surgical…

Angioplasty and Stenting for Aortoiliac Disease: Technique and Results

History of Endoluminal Treatment The concept of endovascular therapy of atherosclerotic occlusive disease was introduced in the 1960s when Dotter performed the first transluminal angioplasty in a patient with ischemic extremities. His novel technique, however, could not reliably maintain luminal patency and did not receive wide acceptance as a treatment of vascular occlusive lesions. Subsequent device modifications led to the development of an angioplasty balloon composed…

Surgical Management of Aortoiliac Occlusive Disease

In the Western world, atherosclerotic occlusive disease of the abdominal aorta and iliac arteries is a common cause of lower extremity ischemia in middle-aged and elderly patients. Although not as common as occlusive disease of the femoropopliteal arterial system, with which it may be combined, aortoiliac occlusive disease may be more disabling because of the greater number of muscle groups subjected to diminished perfusion. The initial…

Carotid Body Tumors: Diagnosis and Surgical Management

Introduction Carotid body tumors (CBTs) are rare and usually benign neuroendocrine neoplasms that have a predictable but slow growth rate and a low potential for malignancy. They arise from the carotid body, which functions as the body's sensor, primarily to O 2 partial pressure. Through afferent fibers of the glossopharyngeal nerve, the carotid body transmits information to the central nervous system. The carotid body is made…

Endovascular Repair of Extracranial Cerebrovascular Lesions

Each year in the United States, nearly 800,000 individuals experience a new or recurrent stroke, accounting for direct and indirect costs of more than $40 billion and untold damage to patients and their families. Stroke is responsible for 1 out of every 20 deaths in the United States, making it the fifth leading cause of death. By 2030, it is projected that an additional 3.4 million…

Surgical Reconstruction of the Supra-Aortic Trunks and Vertebral Arteries

The supra-aortic trunks (SATs) branch from the aortic arch and ascend through the mediastinum to terminate at the carotid bifurcations and the origins of the vertebral arteries. These trunks carry the entire blood supply to the head and upper extremities. The vertebrobasilar system is composed of the two vertebral arteries, the basilar artery, and their branches to the spinal cord, medulla, pons, cerebellum, and cerebral lobes…

Extracranial Cerebrovascular Disease: The Carotid Artery

Historical Review The development of surgery on the extracranial cerebrovascular circulation was dependent on three principal factors: (1) recognition of the pathologic relationship between extracranial cerebrovascular disease and subsequent cerebral infarction, (2) the introduction of cerebral angiography to identify lesions before the patient's death, and (3) the development of vascular surgical techniques that could be applied to the extracranial vessels once the anatomic patterns of disease…

Atherectomy and Arterial Closure Devices: Selection, Technique, and Results

Atherectomy Devices Introduction Since the early 1990s, percutaneous peripheral atherectomy has provided an ancillary approach to the treatment of atherosclerotic occlusive disease beyond angioplasty and stenting. A variety of technologies have been developed to debulk atherosclerotic lesions, including directional excisional, excimer laser, orbital ablation, and rotational atherectomy. These technologies are designed to treat a variety of lesions from heavily calcified stenoses to soft thrombus-containing occlusions. By…

Introduction to Endovascular Surgery: Arterial Access, Guidewires, Catheters, Sheaths, Angioplasty Catheters, and Stents

The core elements of all endovascular procedures include gaining arterial access safely, placing a sheath with hemostasis valve, and navigating to a selected target using shaped diagnostic catheters and guidewires. In most cases, the intervention itself involves use of an angioplasty balloon and deployment of a stent. We will cover this in the current chapter; other, more sophisticated devices will be described elsewhere in this textbook.…

Vascular Grafts: Characteristics and Rational Selection

Despite advances in endovascular interventions, the use of surgical bypass is still both relevant and fundamental to the treatment of a wide variety of vascular surgery conditions. The technical details of the bypass procedure and its subsequent outcomes are dependent on the conduit used. The ideal bypass conduit should be as similar as possible to the native vessel it is replacing. It also needs to be…

Principles of Imaging in Vascular Disease

Currently there are several imaging techniques used to image the vascular system. These techniques include catheter-based conventional digital subtraction angiography, Doppler ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Conventional digital subtraction angiography (DSA) has long been the gold standard for arteriography because of its high resolution and rapid image acquisition. In digital radiography, the x-ray signal is electronically detected, digitized, and processed before…

Noninvasive Vascular Diagnostic Laboratory

Introduction In the early days of vascular surgery, patient assessment was based on a careful history and physical examination. Although a few clinicians used the Collins oscillometer to estimate the pulse pressure in an extremity, there was little help available in terms of quantitative assessment of arterial or venous disease. Angiography provided the only objective determination of pathologic changes. Early experience with arteriography and venography highlighted…

Medical Management of Vascular Disease―Including Pharmacology of Drugs Used in Vascular Disease Management

Introduction Arterial disease is the leading cause of death and significant morbidity in the United States and throughout the world. The American Heart Association estimates that 85.6 million (26.4%) Americans have cardiovascular disease, leading to 787,000 deaths annually. Patients with peripheral arterial disease (PAD) make up a significant proportion of this group, including 795,000 Americans who will have strokes each year. Stroke itself is the third…

Patterns of Diabetic Vascular Disease

Introduction The term chronic critical limb ischemia (CLI) was first coined in 1982 and was intended to describe limb-threatening arterial insufficiency in the absence of diabetes mellitus (DM). Since the initial description of CLI, the incidence and prevalence of DM has markedly increased with a current worldwide prevalence of 422 million, which is a fourfold increase from 1980 figures. Since ischemia accompanies DM in approximately half…

Antibiotic Prophylaxis in Vascular Disease Management

Introduction The use of antibiotics in vascular surgery has undergone significant change in the course of the past half-century. Initial experience with devastating arterial graft infections and significant data supporting antibiotic use led to overuse of antibiotics. More recent experience with restricted use of antibiotics has resulted in a more balanced approach. Our goal in this chapter is to review the use of antibiotics in vascular…

Congenital Arterial Malformations

Definition, Incidence, and Clinical Significance Congenital vascular malformations (CVMs) are rare developmental abnormalities of the vascular system that include a broad spectrum of arterial, venous, lymphatic, and capillary lesions. The overall incidence is estimated at 1.2% to 1.5%. Congenital arterial malformations (AMs) without arteriovenous (AV) shunting are lesions that include abnormally formed arteries or anomalous anatomy due to persistence of the fetal arterial remnants. These pure…