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Atheroembolism

Atheroembolism is the process of embolization of atherosclerotic plaque debris into small arteries and arterioles. Atheroembolism, mainly caused by cholesterol crystals, can occur spontaneously, but more commonly it follows interventional procedures and anticoagulation. Spontaneous atheroembolism as a result of extensive aortic atherosclerosis has been called “the great masquerader” owing to its multiorgan involvement. Since its definitive pathologic description in 1958, more than 1295 citations on this…

Paradoxical Embolism

Paradoxical embolism describes an event in which embolic material originates in the venous system or right heart, passes through any right-to-left shunt, and ends in the arterial system. Although this sequence of events usually is thought to occur with venous thrombus migrating through a patent foramen ovale (PFO), any material (e.g., air, tumor, fat, foreign body) migrating through any right-to-left shunt (e.g., ventricular septal defect, pulmonary…

Arterial Macroembolism

Arterial macroembolism causes significant morbidity and is associated with mortality. In the limb, an arterial macroembolism causes one of the most common vascular emergencies: acute limb ischemia (ALI). Prompt recognition and diagnosis followed by rapid restoration of blood flow to the ischemic extremity decreases limb loss and reperfusion-related local and remote organ injury. This disease most often occurs in aged patients, who often have significant comorbidities…

Complications of Heparin Anticoagulation Therapy

Heparin is routinely used during vascular and endovascular surgery; its use is ubiquitous among hospitalized patients. Vascular surgeons must therefore be familiar with both the major nonbleeding and bleeding complications associated with its use. The most important nonbleeding complications include heparin-induced thrombocytopenia (HIT) and heparin-induced osteoporosis. Bleeding complications often are recognized only after major hemorrhage has occurred. Early recognition and knowledge of predisposing factors can aid…

Role of Antithrombotic Drugs in Maintaining Graft Patency

Graft thrombosis remains one of the more challenging aspects of vascular surgery. In patients with occluded infrageniculate bypass grafts, more than 50% undergo major amputation at 1 year and an additional 15% to 25% die within the first year. The role of platelet inhibition has been well established in patients with vascular disease. The most complete review was accomplished by the Antiplatelet Trialists Collaborative, which reviewed…

Prothrombotic States and Vascular Thromboses

Procoagulant states may be divided into acquired and genetic causes. Acquired factors include advanced age, obesity, malignancy, surgery, prolonged immobilization, use of estrogens, antiphospholipid syndrome (APS), heparin-induced thrombocytopenia and thrombosis (HITT), and pregnancy. Genetic conditions include male gender, antithrombin III (ATIII) deficiency, protein C and S deficiencies, factor V Leiden, prothrombin G20210A, hyperhomocysteinemia, and non-O blood group. Tests exist for the most common hypercoagulable states. Some…

Bone Marrow Stem Cell Treatment for Critical Limb Ischemia

The first U.S. Food and Drug Administration (FDA)–approved randomized clinical trials for saving lower limbs by the patient’s own bone marrow stem cell transplants have been under way since 2007. The initial results are encouraging and provide promise that this form of cell therapy could play a future role in managing advanced peripheral arterial occlusive disease. Aggressive endovascular therapy with angioplasty and stenting and open surgical…

Biologic Therapies for Patients with Critical Limb Ischemia

Critical limb ischemia (CLI) represents the most severe degree of peripheral arterial disease (PAD) manifesting by either ischemic rest pain or tissue loss. In patients with CLI who do not have revascularization options, major amputation is required within 1 year in as many as 40% of patients, and mortality is as high as 20%. Biologic therapies, including gene therapy and cellular therapy, offer the potential to…

Lumbar Sympathectomy for Lower Extremity Ischemic Ulcers

Before the era of arterial reconstruction, lower extremity ischemic ulcers regularly progressed to gangrene and limb loss. Lumbar sympathectomy was first used to treat this condition in the 1920s by Diez in Buenos Aires and Adson and Brown at the Mayo Clinic. Its application was based on experimental and clinical observations by Hunter and Royle in Sydney, Australia, who used sympathetic denervation to treat spastic paralysis.…

Cutaneous Ulcers in the Neuroischemic Diabetic Foot

Ulceration is the most important manifestation of a diabetic foot at risk for amputation. If untreated, the diabetic foot ulcer can enlarge, extend to the deep tissues, and become infected. Deep infection and formation of an abscess can follow and require urgent drainage. Without drainage and intravenous antibiotic therapy, ascending sepsis and septicemia are common sequelae; and if there is associated ischemia, tissue necrosis is virtually…

Pharmacologic Management of Intermittent Claudication

Many pharmacologic agents have been studied for the medical management of intermittent claudication, there has been little success in identifying drugs that significantly alter the natural history of peripheral artery disease (PAD), and so far none has proved superior to exercise therapy. Critically important to the medical management of patients with claudication is the significant cardiac comorbidity in these patients and the need for treatment with…

Exercise in Peripheral Arterial Disease

Atherosclerotic lower extremity peripheral arterial disease (PAD) represents one of the most common manifestations of systemic atherosclerosis and is known to affect approximately 5% of the adult population and more than 20% of patients older than 70 years. As for any atherosclerotic disease, key clinical goals include preserving life and limb, which are best accomplished by creating individualized treatment programs supported by evidence-based clinical care guidelines…

Chronic Compartment Syndrome and Functional Popliteal Artery Entrapment

Atypical claudication symptoms in adolescents and young adults are often associated with athletic overuse injuries and are clinically manifested by isolated muscle group cramping and focal paresthesias on the dorsal or plantar surface of the feet. These complaints commonly have a delayed onset with exercise and last for an extended period after exercise. Atypical claudication symptoms that occur in the absence of obvious vascular disease or…

Popliteal Artery Adventitial Cystic Disease

Adventitial cystic disease of the popliteal artery is a relatively rare cause of lower limb ischemia in which single or multiloculated cysts develop within the adventitial layer of the wall of the popliteal artery. As the typical gelatinous secretions of the intramural adventitial cyst accumulate, the cyst produces progressive obliteration of the adjacent arterial lumen. The reduction of arterial flow leads to the subsequent development of…

Complications and Treatment of Persistent Sciatic Arteries

The persistent sciatic artery (PSA), first described by Green in 1832, is a rare congenital anomaly resulting from the failure of regression of the sciatic artery during the embryonal period. Diagnosis can be difficult, and life-and limb-threatening complications are well recognized. Descriptions and management of PSAs have been limited to several isolated case reports in the literature. The reported incidence of this condition has been estimated…

Open Surgery and Endovascular Management of Failing Infrainguinal Bypass Graft

Originally described in 1984, failing bypass grafts now include any stenosis or abnormal hemodynamics determined by clinical examination, duplex scanning, or arteriography. Although clinical examination provides an initial assessment for vein graft patency, this approach in isolation fails to identify up to 70% of significant lesions. Duplex ultrasound has evolved into the test of choice to identify significant vein graft lesions. Pathology of the Failing Vein…

Surveillance of Lower Extremity Bypass Grafts

Vascular laboratory surveillance of infrainguinal bypass graft function has evolved to a recommended standard of patient care. The rationale for testing is based on the progressive nature of atherosclerosis and the propensity of both autologous vein and prosthetic conduits to develop stenotic lesions that produce a low-flow state and result in graft thrombosis. Infrainguinal vein bypasses, constructed by reversed, nonreversed, or in-situ grafting techniques, tend to…

Percutaneous Mechanical Thrombectomy and Fibrinolytic Therapy for Acute Thrombosis of Lower Extremity Arteries and Grafts

Acute, pathologic arterial and graft clot formation can severely compromise distal perfusion beds of the leg and commonly requires immediate treatment. The decrease in distal blood flow and the resultant tissue hypoxia promote thrombus deposition in the small nutrient vessels. Although a variety of methods can be used for extracting clot from larger arteries, the smaller distal vessels cannot be easily reopened with standard surgical thrombectomy…

Superficial Femoral Artery Endarterectomy for Atherosclerotic Lower Extremity Occlusive Disease

The role for superficial femoral artery (SFA) endarterectomy, either localized or remote (semiclosed), has assumed a less prominent role in current vascular surgical practice. Though described previously, these techniques have been largely supplanted by the well-established superior results of vein bypass for treating SFA occlusive disease. The advent and popularization of a myriad of percutaneous endovascular therapies for treating SFA disease has further rendered this technique…