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Venous Vascular Malformations

Vascular malformations (VMs) are developmental abnormalities of the vascular system. They should be differentiated from vascular tumors or hemangiomas because they have different etiologies, growth patterns, treatments, and outcomes. Malformations can involve any segment of the vascular tree: arteries, capillaries, veins, or lymphatics. High-flow arteriovenous malformations are associated with the shunting of large amount of arterial blood into the venous system. These lesions can have significant…

Nonatherosclerotic Vascular Disease

Although the majority of arterial abnormalities of interest to vascular surgeons are caused by atherosclerosis, a significant number result from inflammatory, acquired, congenital, and developmental abnormalities. This chapter briefly describes the pathogenesis, symptoms, diagnosis, and treatment of a variety of nonatherosclerotic vascular diseases. Topics covered include vasospastic disorders, the vasculitides, heritable arteriopathies, anatomic anomalies, and a variety of other uncommon disease processes that may be encountered…

Atherosclerosis: Pathology, Pathogenesis, and Medical Management

Vascular surgeons commonly treat patients with the manifestations of atherosclerosis. An improved understanding of atherosclerosis and advances in its treatment now provide scientifically based prevention and management strategies. Precise lesion classification, accurate imaging, a better understanding of atherogenesis, and increasingly effective medical treatment before and after vascular interventions all promise to result in improved long-term results. The pivotal role of lipids in the pathogenesis of atherosclerosis…

Hemostasis and Thrombosis

Introduction Most of the bleeding that occurs during surgery or in association with trauma is mechanical and usually can be controlled. In contrast, nonsurgical bleeding most commonly is caused by the concomitant administration of antithrombotic medications, and less commonly by congenital or acquired defects of the hemostatic system. The vascular surgeon must understand the hemostatic pathways and the characteristics of the various antithrombotic agents in sufficient…

Hemodynamics for the Vascular Surgeon

Blood flow in human arteries and veins can be described in terms of hemodynamic principles that provide the theoretical foundation for the treatment of vascular disease. The major mechanisms of arterial disease are obstruction of the lumen and disruption of the vessel wall. The clinical significance of an obstructive arterial lesion depends on its location, severity, and duration, as well as on the ability of the…

Anatomy and Surgical Exposure of the Vascular System

General Principles Knowledge of vascular anatomy and surgical exposures are foundational components of vascular surgery. A detailed understanding of the location of blood vessels, surrounding structures, and the methods to obtain a safe and effective working space around a vessel are critical for any vascular operation. Careful preoperative planning of the approach to any vessel facilitates the performance of the actual operation. Proximal and distal control…

Anatomy, Physiology, and Pharmacology of the Vascular Wall

Normal Anatomy The primary purpose of the vascular system is to serve as a nonthrombogenic conduit for blood flow, which is necessary for the delivery of oxygen, nutrients, hormonal signals, and cellular components throughout the body. The cellular elements of blood vessels, (endothelial cells, smooth muscle cells, fibroblasts, and niche progenitor cells) are similar throughout the vasculature. However, structure and function varies throughout the vascular tree…

Embryology of the Vascular System

It is quite evident that the vascular apparatus does not independently and by itself “unfold” into the adult pattern. On the contrary, it reacts continuously in a most sensitive way to the factors of its environment, the pattern in the adult being the result of the sum of the environmental influences that have played upon it throughout the embryonic period. We thus find that this apparatus…

A History of Vascular Surgery

History is not a precise record, for it is only that which has been remembered or written down. Inevitably, there is much personal interpretation of that original material. In addition, interpreting events from the past is often difficult, and history sometimes changes as new information becomes available. It is often hard for an observer to see recent events in proper perspective, especially when the observer is…

Procedures

I Indications for an Artificial Airway A Absolute 1. Hypoxia—inadequate tissue oxygenation (partial pressure of oxygen [P o 2 ] <55 mm Hg), unresponsive to supplemental O 2 2. Hypoventilation—increasing partial pressure of carbon dioxide (P co 2 ; >50 mm Hg) indicates inability to clear CO 2 3. Acute airway obstruction—refractory to oropharyngeal “finger sweep” or Heimlich maneuver 4. Penetrating neck trauma a. Direct tracheal…

Robotics and Newer Surgical Technologies

Minimally invasive surgery (MIS) describes an approach where major operations are performed through small incisions. MIS encompasses laparoscopy, robotic surgery, and natural orifice transluminal endoscopic surgery (NOTES), surgical techniques that promise to impact the way surgery is practiced. The goal of this chapter is to provide a basic overview of the aforementioned practices and their potential applications. I Single-Incision Laparoscopic Surgery 1. Via an incision at…

Plastic Surgery: Breast Reconstruction

I Introduction Surgical therapy of breast cancer remains not only an important therapeutic mainstay but has also evolved as common prophylactic intervention. Although the techniques of local excision and mastectomy have changed since Halsted’s time, significant disfigurement may still occur. Breast reconstruction can profoundly help a woman’s healing and self-image as she is treated for breast cancer. The Women’s Health and Cancer Rights Act of 1988…

Orthopedic Surgery

I Assessment of the Orthopedic Patient A Basic Advanced Trauma Life Support Principles 1. Airway/breathing/circulation initial assessment 2. Disability/exposure a. Secondary examination of extremities (1) Appearance of abrasions and deep lacerations (2) Range of motion of all joints (3) Presence of crepitance at level of joint or extremity (4) Palpate extremities for areas of tenderness (a) High incidence of missed injuries secondary to distracting injuries (5)…

Neurosurgery

There are many nontraumatic neurosurgical conditions that pose an immediate threat to neurologic function or life. Due to the sensitivity of neurologic structures to insult and the relative lack of regenerative capacity in the central nervous system (CNS), the early recognition of such conditions is critical to prevent disabling neurologic deficit and loss of life. The high morbidity and mortality attributable to these conditions warrant their…

General Pediatric Surgery

I Fluids And Nutrition A Maintenance Fluids 1. Neonates—fluid requirement is 65 mL/kg over 24 hours. 2. By the end of the first week of life—fluid requirements increase to 100 mL/kg over 24 hours. 3. To calculate based on weight: a. [100 mL/kg per 24 hours (4 mL/kg per hour) for first 10 kg] + [50 mL/kg per 24 hours (2 mL/kg per hour) for each…

Cardiac Transplantation

I History 1. The techniques for heart transplantation were developed by Norm Shumway and Richard Lower at Stanford University in the 1960s. 2. James Hardy performed the first heart transplant into a human with a chimpanzee xenograft in 1964 at the University of Mississippi. a. The patient died immediately of acute rejection. 3. Christiaan Barnard performed the first allograft human heart transplant in December 1967 in…

Cardiac Surgery

I Preoperative Evaluation A History 1. History of present illness—detailed account of symptom chronology: acute versus chronic a. Angina—stable or unstable, arrhythmia, congestive heart failure b. Timing of recent intervention c. Dyspnea: New York Heart Association (NYHA) functional classification for heart failure (1) Class I: no limitations during ordinary activity, asymptomatic (2) Class II: slight limitation during ordinary activity (3) Class III: marked limitation of ordinary…

Thymus and Mediastinal Tumors

I Anatomy and Embryology 1. The thymus gland originates from the third and fourth pharyngeal pouches (along with the lower parathyroid glands) and typically descends into the anterior mediastinum. 2. The Shields three-compartment model is the most anatomic model and widely used by thoracic surgeons. 3. Anterior compartment is bordered by sternum (anterior), pericardium (posterior), and pleura (lateral). a. Contains thymus, internal mammary arteries, connective tissue,…

Malignant Tumors of the Lung

I Epidemiology A General 1. Incidence of lung cancer in the United States has been declining among men and only recently began decreasing in women. 2. Overall prevalence is approximately 125 per 100,000 people per year. 3. Estimated new cases per year in the United States: 212,584 (111,907 male and 100,677 female) B Mortality 1. Primary lung malignancies are the leading cause of cancer deaths, accounting…