Behind the Knife ABSITE 2025 - Vascular - Part 2

now let's talk about some more visceral aneurysms. How do you treat a hepatic aneurysm? So that one they cut off is two centimeters in size, and you treat with a resection and reconstruction. Yeah, so you can't coil this because you need the flow to your liver, so you have to actually reconstruct it. Okay what size criteria should you treat an SMA aneurysm? So all SMA aneurysms should be repaired regardless of size. So that's also a resection and reconstruction. Yeah. And you know, I was trying to figure out exactly why that is the recommendation. I think it's because they're thought to be mycotic is the most common cause of an SMA aneurysm. So they need to be fixed. So what size criteria do you use for fixing an iliac artery aneurysm? So, well, first I think it's important to note the association with abdominal aortic aneurysms and iliac artery aneurysms, but the size cutoff is 3. 5 centimeters. That's your criteria for repair. And with these, you can repair them with endovascular stents. Yeah. Many times you can do an endovascular treatment, still some open therapy

also in Almost always associated with some abdominal aortic aneurysm, not always, maybe the same size. Hasn't met size criteria for the aortic part, but still needs to be repaired at the same time. Okay one thing I just want to get across here. Jason, what is the common risk factor now that we're talking about aortic, iliac, femoral aneurysms? What is the risk factor that is by far and away the biggest risk factor? I think for every vascular problem, smoking is probably the number one risk factor. Right, right. So, smoking causes aneurysms and the vast majority of these aorto iliac aneurysms are related to smoking, even if it's a distant. Okay so what size criteria do you treat your femoral artery aneurysms? So, you know, femoral artery is a little bit smaller caliber than the iliac, so 2. 5 historically, but I hear you can observe these up to three and a half. Is that right? Yeah, it sort of depends, but yeah two and a half is sort of the number I keep in my head. But you know, every patient you take into consideration. And so these don't actually rupture, they embolize or thrombose similar to the popatil aneurysms. They don't really rupture. That's not what

you're worried about. But they. These aneurysms get thrombus lining them and then they can cause you know, critical limb ischemia. And so you treat it with a resection and interposition. Just of kind of interest note we've, we talked about iliac artery aneurysms, really referring to common iliacs. We haven't talked about external iliacs. Interestingly, they almost never get aneurysms and it has to do with the embryology of them. I'm not smart enough to tell you that whole thing, but extramedullary arteries, for the most part, don't get aneurysms. Okay, size criteria for treating popliteal artery aneurysms and what workup does the patient need? So, two centimeters or if symptomatic such as an embolic source or thrombosis. The, so the patient, there's, again, there's an association with abdominal aortic aneurysms. So 50 percent of patients with popliteal aneurysms will also have a AAA. So they need a imaging for to look for a triple A. Right. Right. So the patients that have triple A's, only about 5 percent of them will have popliteal aneurysms, but patients that have popliteal aneurysms, half of them will have an associated triple A. So just definitely keep

that in mind. Two centimeters is the size of your pair of them, or if there's a lot of mural thrombus or if it's embolized down the leg. And so most of these are going to need repair. So what are your options for treating popular artery aneurysms? So exclude and bypass or into position with vein is the gold standard. Yeah. So bypassing these is the best thing to do. Make sure you. Ligate your popotheal artery distally so you can't still embolize. So bypass is a great option. Sometimes you can do it from behind the knee. A lot of times we do it on the medial aspect. And then endovascular stints are reasonable in older patients. But you have to make sure that they have good outflow and have multiple vessel runoff. Many of these patients don't because they've embolized from the thrombus and the aneurysm. All right, let's keep going. If a patient presents an acute limb ischemia from a thrombus popped artery aneurysm, what treatment modality should be used? So these patients need to be heparinized immediately and angiogram needs to be performed. So, and

so there's no runoff or semantically diminished runoff a license with TPA to restore the outflow. If you have a good bypass target, distal thrombosed aneurysm, you can go straight to bypass. Right, right. So now we've kind of switched. We're not just talking about our patient that we found the. aneurysm in clinic on a screening ultrasound. This is a patient comes in an acute limb ischemia to the ER. They found to have a pop to aneurysms thrombos. And so if you do your angiogram, cause it can be. Diagnostic and therapeutic. CTA really doesn't show you vessels below the knee very well, especially when you have a thrombosis. So, the angiogram is really helpful there. And you have to lyse these open. Otherwise your bypass or whatever you do isn't going to work because a lot of times the outflow is trashed. Whereas the lysis will really clear that up for you. If on the other hand though, you have a great bypass target. Posterior tibial is massive and in line to the foot. You can just go straight ahead with your bypass and then not have to worry about the blisters. Okay Indications for operating on abdominal aortic aneurysms. What are the sizes

there, Jason? So in men, it's over five and a half centimeters. In women, it's over five centimeters. We also want to look at the growth rate. So if it grows more than one centimeter a year or a half a centimeter in six months that would be an indication for a repair. Great. Yeah. And so there are some of these that can be quote unquote symptomatic if they embolize. From the mural thrombus or cause blue toe syndrome or something like that. That would be an indication also, or if they're infected such as a mycotic aneurysm, you have to repair that. So what patient should be considered for open aortic surgery rather than endovascular surgery? So we'll number one, younger patients. So patients under 70 who have good cardiac and pulmonary function can be considered. Patients with a complex aortic anatomy such as a pair of renal or small iliacs that would complicate an endovascular surgery. Right, right. Yeah. So open surgery is not dead. It's actually kind of making a comeback. And so younger patients with good operative risk factors should be fixed open. And so they, I have seen questions about this. And so, yeah, if it's going to be

really complicated endovascular procedure and they're young, you might as well just do it open. Okay. So when performing an open aa, when do you decide to reimplant the IMA? So if you notice that the IMA has pulse style back bleeding, then there's no need to reimplant. You know, if it has no back bleeding then there's no need to also, no need to reimplant, but it have, it has marginal back bleeding, then you should reimplant it. Yep. That's sort of how we do it. Or sometimes if you have. diSease, other mesenteric vessels, I'll be a little more likely to re implant it. But yeah, if it's pulsatile or not back bleeding you do not re implant it. If there's marginal back bleeding, the thought is that there it needs the perfusion from the aorta. So you, you re implant that. The other reason to re implant it is if they had a previous colonic surgery as they, the collateral networks may have been disrupted. And then also if they You know, obviously if the colon or bowel appears dusky during the procedure, that would be an indication also. Okay. What vein is at risk for injury in an

open AAA when clamping the aorta proximally? Yeah, we talked about this a little bit in some other sections, but the retro aortic left renal vein can be injured as aorta there. Yep. And so you look for this on your preoperative imaging to avoid this injury. Alright, what vessel is at risk when clamping the superceliac aorta and dissecting through the gastrohepatic ligament? Yeah, we also talked about this in other places. So you want to watch for that replaced or accessory left hepatic as it goes in that gastrohepatic ligament. Yeah, okay. So you did a aortic aneurysm repair in a patient. And after starting a diet, they're doing great progressing day three. You, they're on a full diet now and fluid, they get distended and they're not feeling well. And you notice fluid in the belly on an ultrasound. What is this condition likely to be? It's most likely a chylosocytes. And how would you treat that? So you can manage this a lot of times with diet, so low fat, high protein. And you want to have a medium chain fatty acid supplementation. Yep, exactly. So that, that's

any type of retroperitoneal surgery. Urologic surgeries, things like that. You have a risk of causing, disrupting the lymphatic network and causing this problem. So, a patient after an open AAA repair develops abdominal pain and bloody diarrhea. What are you concerned with and what is your treatment? What is your algorithm to treat this condition? So I'd be concerned about ischemic colitis, so I'd want to start resuscitation with IV fluids and antibiotics and to confirm that I may need to do a sigmoidoscopy. Okay, great. And Are you going to rush this patient off to the operating room or how do most of these patients progress? I'm going to try not to. I'm going to try, as long as they're, you know, hemodynamically stable, all those things, and there's no sign of perforation to try and manage them non operatively with supportive care. But if they, you know, develop sepsis, peritonitis and or perforate, then they'll need I would take them for a collect me and perform a Hartman's. Yeah. Okay. So which part of the large intestine is spared from ischemia after a triple A induced colonic ischemia? So that's the

middle and distal rectum because they have a separate blood supply from the upper rectum. Exactly. So the proximal rectum is supplied by the IMA and the middle and distal it comes off the internal iliac vessels, so that is why that happens. All right. So a patient is identified to have a four centimeter abdominal aortic aneurysm. How would you like to follow this patient's for a force of meters? I do yearly ultrasound to watch for growth. Okay, great. Yeah. And if it gets greater than five centimeters, then you start moving your duplexes every six months. Okay. So you diagnosed an infarenal aortic graft infection. What is the treatment of choice? So I'm going to want an extra anatomic bypass. So for that one, I would do an excellent ax fem, ax bifem bypass with aortic graft excision. Yeah. So this is obviously patient and institution dependent, but an ax bifem with aortic graft excision is a great answer because then you're getting completely out of that infected field. You

could also remove the infected graft to breed the tissue and reconstruct to something like deep femoral vein or cryopreserved aorta. But I think the safest answer for the boards is ax bifem with. aortic graft excision. Okay. So say you you did this, say you did the ax bifid with aortic graft excision and the patients in the ICU, um, two days later and becomes profoundly hypotensive and loses consciousness. What are you concerned about? And that's that's it's a scary situation, but I'd be concerned about a potential aortic stump blowout. Yep. So that's the big negative of doing the aortic graft excision is now you have a stump of inferrinal aorta that's basically just ligated. And so you have to do whatever you can to strengthen that. And so you can over so in multiple layers, you can place momentum over the stump. And some people use tensor fascia lata from the leg as a buttress. Obviously it's an infected field, so you can't put a prosthetic material in there. oKay. A patient presents years after an aortic operation with hematemesis and hypotension. What are you concerned

about that? Yeah, that's I would be concerned about a aortic enteric fistula. Yep, definitely. And so what is this? So, so that's when you usually from a chronic inflammation, but you develop a connection between that aortic suture and the duodenum. Exactly. So what if this patient was extremely unstable? They're barely able to keep the pressures up. They're not really meditating. They're transfusing and keeps dropping. What is an option to temporize these patients? So sometimes you can temporize them with a endovascular stance in the aorta. Exactly. Just to temporize the bleeding. Okay. And so say you get them through that initial scary few days. What can you do now that they're then optimized? Yeah, so now you're going to need to do your aortic resection and aortic ligation with an extra anatomic bypass or you could consider inline reconstruction and repair the duodenum. Right, yeah. So you're going to have to ask your general surgery colleagues for some help here. You're going to have to take that duodenum off. Once again, you could use something like deep femoral

vein or cryo aorta if you wanted, but I think extra anatomic bypass is probably the best answer. Is that what you would say on the upside? Is it extra anatomic bypass? Yeah, I think extra anatomic bypass, yeah. Okay. Because cryo vessels really don't have very good patency, and deep femoral vein is very You have to know what you're doing and not many places do that. Okay. So when you perform an aorta bifemoral bypass, how do you decide between an end to end aortic anastomosis versus an end to side anastomosis? So, well, first you need to ensure flow into at least one internal iliac for pelvic perfusion. So if the external iliacs are patent, you can perform an end to end as is you know, the patient will have an internal iliac perfusion from retrograde flow. If the external Iliacs are not patent then you can perform and decide which allows antigrade flow into the internal Iliacs assuming the common Iliacs are patent of course. Right. Yeah. So just kind of draw this out or think about it for a minute. It's definitely been

tested. I think it was like my intern year and I had zero idea what they were talking about. But you have to get flow to that pelvis some way. And so if your external Iliacs are patent, you'll get that retrograde flow into the pelvis. They're not, then you need to do the end decide to allow whatever native flow into the pelvis is occurring to continue. So how do you tunnel your aero biformal bypass in regards to the ureters? So you tunnel under the ureter to prevent the development of hydronephrosis. Yep. And the way I just remember this is. You're replacing the vessel, and so you just stay right on top of the vessel. So you tunnel right on top of your iliac artery, which is underneath the ureter, and then you're good to go. Alright You have a frail patient that presents with an occluded aorta, but cannot tolerate an aorta bifemoral bypass. What other reconstructive options can you offer her? So, an ax bifem is, it is a good, you know, durable option. It's, you know, less traumatic on the patients and has acceptable patency rates. Yeah,

exactly. So ax bifem is your kind of go to aortic reconstruction option and infection or sick ill people. All right. So let's just talk quickly about EVAR, endovascular aortic repair patient can't undergo an open surgery or something. What are some of the kind of buzzwords criteria that we need enabled to be able to perform an e bar? Yeah, so these are numbers that you have to know, and these are testable, so your neck diameter less than 32 millimeters, a neck angle less than 60 degrees, a neck length of at least 10 millimeters for your landing zone, and iliac diameters of at least 7 millimeters in order to accommodate that device. You also need to have a lack of thrombus or calcification in the infernal neck. So, you know, the way that I would ask that question is I would give you somebody that had a very torturous or an angle that was over 60 degrees and ask what your options are for repair. Yeah, exactly. The ones I've seen

come up most often is they'll give you an iliac artery. That's very small, like four millimeters. and say, you know, is this a patient, a candidate? And so no, the other one is the really critical one is the neck length. You need enough healthy aorta below the renal arteries for that graph to seal in. If you don't have healthy aorta, that graph can't seal. The graph is not going to work at all. So you need 10 millimeters of healthy neck. So if they say, A pararenal, juxtarenal, that all means there's not enough length at the neck. And so that's another area where they just do not qualify for an EVAR. Speaking of having a short neck and causing problems, let's talk about endoleaks. So, if you couldn't seal that neck or you tried to seal that neck and it, Did not keep that seal. That's called an endo leak. So, Jason, what are the four types of endo leaks? Briefly? Yeah. So there's type one through four and one is broken up into type one A or type one B. So type one is a is means that the graft isn't sealed at either the proximal or distal import. So again, that's pro one A is proximal and one B is

distal. Type two is lumbars or the IMA. Continual to, you know, fill the aneurysmal sac. So type three is when components of the endograft are not sealed between the components, and type four is due to porosity of the graft itself. Or a tear in the graft. Yep, exactly. So your type one and your type three mean that your aortic sac has the same exact pressure that it did before you fix this, you've done nothing to help these patients. Or and their aneurysm is likely growing. So you need a type one in a three. You have to fix, you know, not emergently, but re in a reasonable amount of time. And so for a type one, you generally have to place a cuff to seal more proximally or do a fenestrated graft, more proximally or distally. You have to extend further distal a type three. The components they're just not connected. Well, there might be over not enough overlap between them. So you have to kind of fix that. Type two is where your lumbars or your your IMA is filling the aneurysm sac. So you only need to

fix this if your aneurysm is growing. It's normal to have some type two endo leaks. And you can treat that with coil embolization of the, of whatever vessel it is. And then type four is, yeah, the porosity of the graft. So you have to, or as a tear in the graft, so you have to basically reline it. Okay. And otherwise healthy patient presents the primary care clinic with chronic upper abdominal pain. And they were found to have evidence of celiac artery compression on a CT scan. What is this name? What is the name of this disease? And how would you confirm it? And what are some surgical treatment options? So this is MALS or MALS or median arcuate ligament syndrome. So the core of the diaphragm are compressing your celiac artery. And it's associated a nerve tissue. So if a celiac, so what it would do is you'd get a celiac plexus block. And if that relieves the pain, it can help confirm the diagnosis. Treatment involves releasing the cora off the celiac artery and decompressing that nervous plexus. It can be done open or

a lot of people are doing it minimally invasive, elapscopic or robotic approaches now and usually these patients will not need arterial reconstruction unless they have evidence of aneurysmal degeneration. Yeah. So it's in the vascular chapter and vascular surgeons take care of this, but it's really a nerve issue. It's compression of that celiac nerve plexus that causes that chronic pain. It's not the compression of the vessel. So, but yeah, you if they can't deal with it, you gotta do an open release or a, you gotta release that crew off the vessel and the nerves. All right, we're going to go to Jason's favorite topic here. Peripheral vascular disease. Yeah. All right. So very high yield those stuff here. All right. How do you calculate an ABI, Jason? So you take whichever fetal pressure is the highest either the DP or the PT and you divide that by your highest brachial pulse of the right or the left arm. Yeah, right. Yeah. So you pick whatever the highest of the DP or the PT and then whatever arm is the highest.

Okay. So just kind of briefly, how do you, what are the categories for ABIs? So normal is anywhere from a 0. 9 to 1. 4. If you have, once you get down to 0. 5 up to 0. 89 or below nine, you may have claudication. You start seeing rest pain at ABIs less than 0. 5 and tissue loss at ABIs of less than 0. 3. Yeah. So, you know, all of our patients, we get ABIs and toe pressures on. And so down in Texas not many people have compressible vessels. Our ABIs are almost worthless down there. So, what can we do? If the ABIs are telling us, Oh, the ABIs to a lot of times, a lot of our patients what should we do there? So, well, if you have not crystal vessels that you have, like, like you say, falsely elevated ABIs, so you can get toe pressures. And cause these. Smaller vessels are generally free from that calcification. Right. Yeah. And I don't put it in here, but we can get TBI's also. So, so instead of the arterial brachial index, you do a toe brachial index. And if

that's greater than 0. 7, that's normal. And we're not gonna go through every part of that, but less than 0. 7 abnormal. okAy. So, Jason, you have a patient that comes in and he says, man, my legs hurt when I play golf. Can you fix me please? I walk a certain distance. It recurs every time and I rest and it gets better. I was a former smoker. What is this disease process called it and how do we treat the vast majority of them? Yeah, so this is very common claudication. First is lifestyle. So smoking cessation exercise and statin and then an addition of a statin therapy for medical therapy. Exactly. All right. So he says, all right, sure. What kind of exercise should I do? Yeah. So this is a, there's a structured exercise therapy for this. So what you do is you have the patients walk until they experience that pain from claudication and you tell them to walk through the pain for a moderate distance. And over time they should be able to increase that distance. Yep. So this can be oral boards. This can be all your claudication patients. They need to be medically managed and put in through an exercise. Program

and they need to actually walk through the pain to help improve is much, much safer than treating their disease with a stent or bypass or something like that. So, what does medical therapy include when treating these patients with peripheral arterial disease? So we, like we talked about smoking cessation is very important. A high dose statin with a goal of a LDL less than a hundred and then a addition of a anti platelet medication. Right. And it's important for these patients to know that there are other vessels in their body look likely look like their blood vessels in their legs. So you're also saving their life. You know, preventing heart attacks and things like that that can kill them. They really need to get medically managed appropriately. So what indications would you intervene on a patient with claudication? So if it's lifestyle limiting and it's, we've done all the things and it's failed certainly if patients start experiencing rest pain, that, that would make me concerned. And especially if they have a tissue loss. Great. Okay. Let's just briefly cover kind of how we image blood vessels. What are some of the ways other than ultrasound

that we can use? So CTA is a great option. We have our, you know, more traditional angiography. You can be, do either using a contrast or CO2 angiography. And then our magne, our mrm MRA or our magnetic resonance angiography. Yeah. And so I think it's just good to know CTA A is not really good for vessels below the knee. It's just hard to time it right and get good visualization. And angiograms really gonna give you where we, you know, put a catheter up and over and take a picture. It's can really help you a lot more. Okay, Jason, now you have a patient who has rest pain, okay, and they have a SFA occlusion. What kind of principles are going to help you decide whether you're going to treat this open or endovascular? Yeah, I know there's some, you know, kind of classifications for these types of things, but in general endovascular interventions are best for lesions that are short and not heavily calcified. Long inclusions with dense calcifications are likely better treated with open bypass versus

endarterectomy. Yeah. So, yeah, if it's a short, easy lesion to treat, if they're giving you a case where you have Good inflow. Yeah, they show you a good tibial vessel outflow. And they say the saphenous vein is beautiful. It's three millimeters throughout. Then I would lean towards open surgery. Femoral the common femoral artery is and same thing with the popotile artery, we never really stent these areas because they're so much mobile, they're so mobile, and they're prone to kinking and breaking the stents. So for the common femoral artery and the popotile artery we, especially the common femoral artery, we lean towards open approaches there. All right. So there's a few ways that we treat blood vessels endovascular and kind of very broad terms here. I've seen questions on this is why I added it. So Jason, what are sort of like the three sort of main things we can do to a blood vessel? Yeah, so you can perform balloon angioplasty, you can stent, or you can perform an arthrectomy. Yeah. Okay, so balloon angioplasty, most common, but you really are risking creating a flow limiting dissection in the vessel. And then even if

you do get a good result, it's going to be relatively, it's not going to be patent for particularly long. So it depends what you're doing this for. Stenting is a lot of times something we use after we balloon angioplasty. This has better patency than angioplasty, but you risk thrombosis of the stent over the long term. And so, and stent fracture. And like I said, we do not stent in the common femoral artery and try not to sit in the pop shield artery due to the high mobility of these areas. And then atherectomy is the rotor rooter of the blood vessels. The biggest problem with atherectomy is you risk embolizing. You can imagine putting a little drill down a blood vessel full of plaque and things that you're going to send plaque distally. And so you can create a patient that had claudication or rest pain and turn them into a. A tissue loss patient or you know, acute limb ischemia if you embolize down the leg. So if you're looking at a question where you're considering which one to do and they tell you they have three vessel runoff atherectomies may be reasonable in that situation. If they have a single vessel runoff, you're not going to want to do atherectomy. And then generally with atherectomy, we place the little baskets to help embolization protection devices.

Okay. That's as much as I can tolerate talking about that on the general surgery curriculum here. JaSon, so a patient presents with buttock claudication impotence and absence of femoral pulses. What is this syndrome called and where would you expect the lesion to be? Yeah, I can never remember if it's Lerici or Lerici. I say Leriche. Leriche? Yeah. I wasn't even close. So, these are aortic iliac symptoms. So, this patient would be a candidate for aorta bifemoral bypass or, you know, there's possibly endovascular options. Right, right. Yeah, so this is a common iliac or distal aortic lesion. And so aortofem bypass versus a Iliac stentine is probably good options for him. So since I've started doing a lot more Peloton, is this something I need to worry about? No, you need to worry about Iliac endofibrosis. But we're not going to talk about that today. Okay. Maybe offline. You can tell me about that. Okay. So if a patient presents with a thrombosed bypass graft, what is the likely ideology based on the time of surgery? Okay.

So if it's early like less than a month, that's probably something technical in that first two years. So that one to two months, all the way up to two years, that's neo intimal hyperplasia. And then over two years, that's atherosclerosis. Exactly. Yeah. So if it goes down quickly, technical over the first two years, that's the inflammation. That's the neo intimal hyperplasia. Okay. So, a patient presents with a large acute embolus that larges at the lodges at the aortic bifurcation. How does this differ in regards to treatment options to Lariche syndrome? So, so embolic disease, you have an option of transfemoral, retrograde embolectomy bilaterally. LRE syndrome is an atherosclerotic disease in which a bypass would be indicated. Yeah, so I just, I put this in there 'cause some people kind of think that any, you know, occlusion at the same

level is the same thing, but. Imbolic disease versus atherosclerotic disease is very different and it presents very differently. The embolic disease is going to be a very acute, very sick patient because they are not used to having low blood flow, whereas the atherosclerosis is going to be the kind of slow building plaque and calcification. So, if it, if you have a. If you get a question where you have a patient AFib and they come in with bilateral cold legs and they have a embolus at the aortic bifurcation, you can do bilateral femoral cutdowns and do embolectomies of the iliac arteries and you know, not aorta bifib for this patient. Okay. So we're just going to quickly talk about different levels here. A patient presents with thigh claudication. Where would you expect this lesion to be? Thigh claudication, I would think a iliac lesion. A patient presents with calf claudication. Where would you expect this to be? SFA. Great. Okay. So now you have a patient that tells you he has this leg pain but you got ABIs on them. Your nurse put them in and got ABIs and they're normal. And so what do you

want to do to make sure he doesn't have vascular disease that you're missing out on? I would do that patient at walking treadmill test. Exactly. So you have them walk until they experience the pain and then you recheck their ABIs. As proximal iliac lesions can have normal ABIs due to collateralization. but with exertion, you'll see a significant drop in their ABI. So you can miss iliac artery blockages. If you just do a normal ABI a patient with a fib presents with acute new onset foot pain for two hours and has diminished pulses. How do you evaluate this patient and determine the urgency of revascularization? Well, it sounds like acute limb ischemia based on what you told me. So, I would do a vascular exam to include Doppler signals and a motor sensory exam of the foot. Okay, yeah. So, in a patient where you have a concern for acute limb ischemia, Knowing their signal exam in their foot and their motor and sensory is what's going to drive the entire management. So for Rutherford 1, you're going to have diminished arterial signals in the foot or normal but no significant

motor or sensory loss. With Rutherford 2A your arterial signals are going to be diminished or not present, and you're going to have some sensory loss, but no motor loss. So in this case, semi urgent revascularization is required. 2B, This is where you have all of the things above. So you have no arterial signals. You have seen, you have sensory loss, but now there's evidence of motor loss. So this is the most urgent revascularization. Once you have motor loss. And then refer Rutherford's three, you have no signals, you have no motor, you have no sensory. The foot is non salvageable at this point. So Rutherford one, I didn't say the management for that. Generally you heparinize these patients and you get a CTA and you figure out a time to fix them. Two a and two B are the urgent ones. Two a's not, Probably not going to get up in the middle of the night to treat anticoagulate them and do it first thing in the morning. 2B is, you get up in the middle of the night and go in and treat that. So, Jason, is a patient with Rutherford 2B ischemia a candidate for endovascular lysis therapy? Generally not because it can take over

six hours to be effective and you run the risk of having permanent damage by that point if you're waiting to restore for that long time. Right. So this is the patient that you're probably going to do an open or endovascular thrombectomy on for urgent restoral flow. Okay. Where is, we've mentioned this in our quick hits before, but what is the most common site for an embolism to lodge in the leg? Yeah. So you're looking at your, really your bifurcation points. So most commonly at the femoral bifurcation with the profunda and the SFA. And then the second most common would be distal and the popliteal artery as it bifurcates. Yeah. And so as it bifurcates, you're getting one bigger vessel going to two smaller vessels. So it was a certain size and it gets caught as the vessels narrowed. Okay. I'm just going to talk to you guys through this. It comes up, go to Google image right now. If you're not driving or running, you need to know the basics of an angiogram. You need to be able to identify the vessels as they come off throughout your leg angiogram, because sometimes they will ask you this. So just for below the knee you have your

popotial artery. And then the first. Major branch coming off laterally the bigger one and it has like a it goes horizontal for a minute is the anterior tibial artery then it goes down into your tibial peroneal trunk And then there's a fork there after your tibial peroneal trunk the one that goes straight down is your peroneal artery The one that kind of goes medial is your posterior tibial artery So the anterior tibial artery and the posterior tibial artery actually run on to the foot as the DP and PT I know it's hard to hear that but just kind of look that up cause it is testable. Just Google image, search that and quiz yourself, you know, point the pointer cursor at different things in that lower leg arteriogram and see if you can name those structures. Exactly. All right. So Jason, we're going to talk a little bit about more about compartments. What are the four compartments of the leg and what do they contain in each of them? So there's the anterior compartment, lateral compartment, and then you have both superficial and deep posterior compartments. So so with your anterior and lateral, you'll release

these with your lateral fasciotomy incision. And so the anterior compartment has the anterior tibial artery. And your lateral compartment contains that superficial peroneal nerve. So going back to your posterior, so you have superficial and deep. So the superficial contains the gastrocnemius and sural nerve. And then your deep contains the tibial nerve your posterior tibial artery and your peroneal artery. Okay. So Jason, what vessels does diabetes primarily damage? So that's your tibial vessels as well as your small vessels and your microvasculature. Okay. So you have this foot wound that you're seeing in the ER doesn't probe down to bone. The x ray looked relatively normal. What is, what modality is the most sensitive for diagnosing osteomyelitis in a foot? Yeah, your most useful test is going to be your MRI. Great. Now, how do you manage a diabetic foot ulcer with osteomyelitis and lenderline bone? So you want to you know, debride back to healthy

bone and then they're going to be on a prolonged course of antibiotics, like up to six, you know, six weeks. Right. Great. And so any of these patients that have these diabetic foot wounds, you got to make sure they have adequate perfusion. So generally we start with our ABIs or our non invasive flow studies. If these show that the flow is impaired and the patient needs an angiogram then that's the next step they should go because the angiogram is both diagnostic and therapeutic. And so you wait to perform the definitive foot surgery or debridement until revascularization is maximized. How do you manage a patient that presents with evidence of foot infection along with severe peripheral arterial disease? So you want to first manage the infection. So resuscitate and antibiotics and then you will want to revascularize, but you know, treat the infection first. Right? Yeah. They'll, there's been questions where a person comes in with a quote unquote hot foot. There's their borderline septic, their white counts really high. There's pus draining out of their toe. You don't wait to,

and you don't take them for an angiogram that night. You take the toe off. Or open the foot wound drain it just like you do in many other aspects of surgery. Source control. Exactly. All right. We're going to go talk about everyone's favorite topic, venous disease. Okay. So some big topics in venous disease first before we get down to like the more common stuff. Jason, how do you approach the left common iliac vein, say it's a trauma situation? Yeah, okay, that can be very challenging to get to and sometimes you'll have to actually divide the right iliac artery that's sitting right on top of it. And then you'll have to repair that, of course, after you deal with the venous injury. Exactly. And so this is why you have May Therner syndrome, right? Because the iliac, the right iliac artery is laying over top and compressing the left common iliac vein. So you have to sometimes you know, divide the iliac artery. Okay. So Jason, what veins can be ligated in trauma? So, well, most of them, but it's so. You can ligate

really anything distal to the renal veins but just be aware that the more proximal you are to the renal veins or the higher up you are, the higher the morbidity but certainly if a patient's bleeding to death and you have to ligate, you can just remember that you may I want to do a you want to consider doing a prophylactic fasciotomy for a lot of those venous ligations. Right. Yeah. You can ligate the IVC, you can ligate an iliac vein but they're going to get venous claudication in both of their legs. They're going to, they're going to be limited, but you know, if that's what it takes to save their life, make sure you do the fasciotomies. And you know, it is what it is. Can you divide the renal veins? Yeah, I think we talked about this a little bit in one of our other chapters, maybe the trauma chapter, but you can divide the left renal vein proximal to the gonadal best vein. As long as that's left intact because you'll get collateral and a retrograde drainage through that. Perfect. A patient presents with unilateral leg swelling and only deep venous reflex seen on the duplex ultrasound. What can you offer this patient? Boy, you can conservative things like

compression stockings and elevation. Yeah. So come over to vascular clinic. You'll get to offer this about 10 times every clinic. With deep venous reflux there's no good surgical options at this point in time. They are looking at the valve transplants and things like that, but that would be for people that have severe wounds and things like that from most patients that have just the leg swelling or can get better and be helped with compression stockings and elevations. So a patient presents with unilateral leg swelling that worsens throughout the day and is found to have reflux in the greater saphenous vein greater than 500 milliseconds. The reflux is seen from the saphenothermal junction all the way down to the thigh. What treatment options are available to this patient? Yeah, so this patient has greater saphenous vein reflux. And so there are ablation techniques that are pretty effective. So either heat ablation or chemical ablation. Yep, exactly. So this is a patient that you can really give a, give them a good result here by either heat ablation through RFA catheter or through a laser.

And now there are some chemical ones which we'll talk about a little bit more here in a second. So, a patient has symptomatic greater saphenous vein reflux but is isolated to the below the knee portions of the greater saphenous vein. So, it's all below the knee. What is the best option in taking care of this patient? Yeah, so your heat ablation is usually only used above the knee and that's due to risk of injury to your saphenous nerve below the knee. So, this patient would be a candidate for a chemical ablation. Right, yeah, so the chemical ablation is either glue or sclerosin. I don't think they get into brand names, but the glue currently is venaseal, the sclerosin is verathina. And so this was great for below the knee greater saphenous vein because there's the nerves more closely associated and more nerve injuries when, so generally we do not do heat ablation below the knee. We just do that for above the knee. So the other thing you want to make sure before you do a heat ablation above the knee is that the saphenous vein is deep enough and it generally needs to be five milliliters deep which most are, but you want to make sure that because you could burn the skin

if the saphenous vein is not deep enough. Alright, so now you have a patient and you're taking them for the greater saphenous vein ablation. How far from the sapheno femoral junction should your catheter be? And, What if on your post op ultrasound, you notice that there's thrombus encroaching on the sapheno femoral junction. What is this called? Yeah, I actually remember this from doing these when I was a resident, but yeah, so you want to be two to three centimeters from that sapheno femoral junction and the clot encroaching it's called endothermal heat induced. Thrombosis. Exactly. So thrombus within the greater saphenous vein is normal. That's what you're basically doing. You're causing it to scar down and that's okay, but we don't want that thrombus approaching the deep femoral vein where the, at the sapheno femoral junction. And so that's why we pull our catheter back into the greater saphenous vein to prevent that from happening. So Jason just kind of in broad terms, I don't think it's important to know the different like classifications. I just think there's kind of

in my, the way I think of e hit is in three ways and that's how I recommend you guys thinking about it. So what are the, you have this thrombus that's a little too close to the saphofemoral junction. Kind of, what are those three kind of categories and how do you treat it? I don't know. I think I'm going to need you to walk me through this one and you're tapping me out. So, if the thrombus is actually protruding from the greater saphenous vein into the common femoral vein, you basically have a DVT at that point. And so that patient needs full anticoagulation, likely for three months, is the safe answer. Now, if you have thrombus that's flushed with the common femoral vein, there's two different courses of action you can do here. You can just repeat the imaging versus a short trial of anticoagulation depending on how reliable the patient is, how worried the patient is about that. Cause that's not a dbt but certainly it's close. So that would be an option for there. Now if you have thrombus within two centimeters of saphir femoral junction, generally we just do repeat imaging on them within a week or two. To make sure that it's not progressing and it's very unlikely to progress. So I think the way that the only

way that I think they're going to ask that on the outside is they're going to give you that one with the thrombosis entering the common femoral vein and the answer is going to be anti coagulation. Right? Yeah. Yeah. Or, you know, just within two centimeters and do nothing, you know, repeat image. Yeah, sure. Yeah. Okay. And so in what situations would you be willing to offer someone a greater saphenous vein stripping? So, I, I feel like that's less with the newer ablative techniques that's less common, but if they have large greater saphenous veins that are too close to the skin like you mentioned, or yeah. So really big greater saphenous veins. So we're talking like greater than two centimeters. The catheters can't scar those down or it's too close to the skin or kind of through the main reason. Some people have failed previous ablative attempts and that would be a reason to try it. But yeah, it's pretty rare. But it is still done somewhere. All right, Jason how are spider veins or articular veins generally treated? Oh yeah. I remember doing this as a resident in clinic too. It's very satisfying actually.

And that's that those chemical sclerosants that you can inject the sclerotherapy. Yep. Yep. So polydocanol or sotradecol are the two ones you can use and you inject them. Okay. All right. We're wrapping up here. We're on our last major topic. DVT management. Okay, Jason, you have a patient that presents with a swollen blue leg up to the buttocks. Their motor and sensation is intact. What are you worried about and what is the treatment? Be worried about a phlegmasia cerulea dolens. So that's a iliofemoral DVT. And I would want to give you a call so you could come in and do some catheter directed thrombolysis, right? Yeah. You can do catheter directed thrombolysis. You could do Thrombect you know, catheter thrombectomy also are both good options but motor instensation's intact so your hand's not forced in this situation. Many times we do it to prevent post thrombotic syndrome especially if it's an iliac, iliofemoral DVT but. As long as they have motor and sensation intact, you can wrap the leg, elevate it. That should be a critical part of all of this. And then

plus or minus some thrombectomy and thrombolysis. Okay. So Jason, what is the most common location for DVT and which leg has a higher rate? So, iliofemoral DVTs are the most common, and the left leg is twice as likely to have a DVT than the right. Exactly, and that's because of that compression by the right common iliac artery. Okay. What if a patient is diagnosed with a DVT but has a contraindication to anticoagulation such as a recent brain bleed? What can you offer this patient? IVC filter. Great. Where should an IVC filter be placed in relation to the renal veins? So you want those to be a cod ad to the renal veins below your renal veins. Great. Okay. So we're gonna talk about anticoagulation briefly. So you have a provoked dbt. Someone just had surgery or they had trauma and they got a dbt. How long are you anticoagulate them? About three months. Okay, great. Patient has active cancer and they got a dbt. How long are you gonna treat them and what are you gonna treat them

with? So, they should just continue therapy really indefinitely until their cancer is cured or resected and then for a period after that, but they should be receiving Levinox. Great. Patient has a hypercoagulable disorder. Lifelong. Great. A patient presents with a painful cord on the inside of his leg. Duplex does not show DVT, but did demonstrate that the greater saphenous vein was thrombosed for approximately 10 centimeters. What is the diagnosis and how is it managed? So this is superficial thrombophlebitis. So, if it's focal like less than five centimeters and not near the saprofemoral junction, it can be managed with NSAIDs and warm compresses. It's probably going to be the answer on the test. So a a longer thrombosis or if it's near that saprofemoral junction you would want to treat that with anticoagulation. Yeah. And so what they're recommending nowadays is the Fondo Paranox 2. 5 milligrams for 45 days. So just remember the Fondo Paranox for a long, if there's a

long, a superficial thrombophobitis, or one that's close to the staph enfermal junction, you're obviously trying to prevent this from becoming a DVT. Okay. So patient presents with a chronic non healing wound of the medial malleolus of the left leg. Okay. What is the likely cause given the location and what should be the first line treatment modality? Yes, this is a chronic venous insufficiency and the treatment is an UNA boot. So that's multilayer compression bandage that they'll wear for five to seven days at a time. Yep, exactly. So medial malleolus classic board question. Compression is the right answer. If they fail compression treatment, then you can talk about doing ablation therapies and things like that. Okay. How do you differentiate lymphedema from venous insufficiency? So, lymphedema will generally involve swelling of the feet, whereas venous insufficiency actually stops at the ankles. Yeah, so what is that sign called to check the, you pinch the skin of the toe? I have no idea. Stemmer's sign. Oh, okay. And so if

you can easily pinch the skin of the toe, they unlikely to have lymphedema because lymphedema has very dense tissue. So a Stemmer's sign shows you that if you can't pinch it, that they do have lymphedema. Okay. And so what are the management principles of lymphedema, Jason? So, compression and decongestant therapy. So, that's some specialized massages to help drain the lymph from the leg followed by compressive therapy. So essentially compression therapy. Exactly. Okay, great. Now let's do some quick hits to wrap out vascular here. Jason, how do you access the SMA quickly? So, SMA lifts the transverse colon and you mobilize your LLT. Great. How do you expose the superceliac aorta and trauma? Enter the lesser sac through the gastrohepatic ligaments and then you you know, divide the cruise of the diaphragm. What is the biggest risk factor for ischemic colitis in a patient with a ruptured aneurysm? Preoperative hypotension. You have an old lady with headaches and temporal blindness and fatigue. What is this and how do

you treat it? So this is most likely temporal arteritis and you treat this with steroids. And you diagnosed it with a temporal artery biopsy. Perfect. Alright, what vessels are affected in Berger's disease? Berger's disease is that's a small to medium sized vasculitis. Yep, these are the smokers that have the corkscrew vessels and they have to stop smoking. Okay you have a mycotic aneurysm. What is the most common organism? Staph. Great, not salmonella. Okay, great, well, that wraps up vascular. That was exhausting. Dominate the day.