Essentials of Vascular Surgery for the General Surgeon Vivian Gahtan Michael J. Costanza Editors 123 Essentials of Vascular Surgery for the General Surgeon Vivian Gahtan (cid:129) Michael J. Costanza Editors Essentials of Vascular Surgery for the General Surgeon Editors Vivian Gahtan, MD, FACS Michael J. Costanza, MD, FACS Chief, Division of Vascular Surgery VA Health Care Network Upstate and Endovascular Services New York at Syracuse SUNY Upstate Medical University SUNY Upstate Medical University Syracuse, NY, USA Manlius , NY , USA Lead Physician, Vascular Surgery Vascular Surgeon Department of Veterans Affairs Healthcare Department of Veterans Affairs Healthcare Network Upstate New York at Syracuse Network Upstate New York at Syracuse Syracuse, NY, USA Syracuse, NY, USA ISBN 978-1-4939-1325-1 ISBN 978-1-4939-1326-8 (eBook) DOI 10.1007/978-1-4939-1326-8 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014950048 © Springer Science+Business Media New York 2015 T his work is subject to copyright. 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Violations are liable to prosecution under the respective Copyright Law. T he use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Prefa ce Strictly defi ned, vascular surgery involves performing procedures on blood vessels outside the heart and brain. Although this defi nition is technically accurate, it only scratches the surface of vascular surgery in the twenty-fi rst century. Vascular surgeons operate on arterial and venous disease, repair hemorrhagic injuries, perform endovascular interventions, create vascular access, and manage diabetic foot infections to name just a few areas of practice. Although vascular surgery emerged as a subspecialty in the 1980s, this fi eld still plays an important role in general surgery training and practice. Since fewer than 3,000 board certifi ed vascular sur- geons practice in the USA, many general surgeons rely on their vascular surgery experience during residency to treat patients with vascular problems. In a recent review of operative logs from nearly 5,000 surgeons, the American Board of Surgery found that general surgeons per- formed 46 % of vascular surgery procedures [1]. Although efforts to increase the number of vascular surgeons have begun, general surgeons will continue to care for vascular patients given the rapidly increasing elderly population and the comparatively small number of resi- dency and fellowship trained vascular surgeons entering the work force each year. Unfortunately, the training that general surgery residents receive in vascular surgery has become less consis- tent as vascular practice moves toward endovascular therapy. For many general surgery resi- dents, the breadth of their case volume in vascular surgery experience has narrowed to dialysis access, amputation, and varicose vein management. Therefore, fi nding an appropriate reference book for general surgeons who treat vascular patients can be challenging. Multi-volume textbooks of vascular surgery provide an extremely detailed and comprehensive approach to vascular conditions that may not readily translate into real-world practice. At the other extreme, general surgery textbooks condense vascular surgery into a few chapters that often lack the technical details and treatment guidelines valued by a practicing surgeon. This book directly addresses the needs of general surgeons who perform vascular surgery during residency training, clinical practice, or both. As a clinically oriented resource this book focuses on the diagnosis and clinical management of vascular conditions while describing the technical details and pitfalls to avoid when performing common vascular surgery procedures. Ideally this book will serve as a “one stop” information source that sur- geons and trainees will turn to as a valuable reference, surgical atlas, and study guide. The contributing authors have used clear illustrations and evidence based treatment recom- mendations to create clinically relevant chapters. The fi rst chapter provides an organized approach to the vascular patient with an emphasis on history, physical exam, risk factors, and diagnostic options. Most vascular conditions require some form of physiologic study or imag- ing exam to clarify the diagnosis and assist with treatment planning. Chapter 2 lays the founda- tion for successful vascular surgery by illustrating common vascular exposures and describing fundamental technical principles unique to arterial surgery. The rest of the book is organized into parts on arterial disease, venous disease, vascular trauma, vascular access, and complex vascular conditions. The chapters on acute arterial disease outline the management and surgical techniques for the treatment of acute limb ischemia, compartment syndrome, and diabetic foot infections. Restoring fl ow to an acutely ischemic limb is one of the defi ning interventions of vascular sur- gery. In many cases, an expeditious surgical thrombectomy as described in Chap. 3 can be the v vi Preface difference between limb salvage and major amputation. Likewise, compartment syndrome re presents a limb threatening condition that may require immediate intervention by a general surgeon. Chapter 4 explains and illustrates the steps involved in a fasciotomy which can be a limb saving procedure. Diabetic foot infections are included in this part (Chap. 5 ) because of their tendency to require acute surgical intervention. Failure to recognize and adequately debride diabetic foot infections when indicated can have devastating local and systemic consequences. C hronic arterial disease is addressed in chapters on the management of claudication, critical limb ischemia, and lower extremity amputation. Peripheral arterial disease (PAD) affects tens of millions of patients and can cause disabling symptoms. Chapter 6 discusses the diagnosis and risk factors associated with claudication while providing an overview of the medical, endovascular, and surgical treatment options. Chronic critical limb ischemia can manifest as ischemic rest pain, non-healing ulcers, or gangrene. Chapter 7 focuses on recognizing critical limb ischemia and preparing patients for limb salvage which may involve surgical, endovascu- lar, and medical therapy. In some patients, complete limb preservation is not possible and an amputation is required. A well performed amputation of the toe, forefoot, or leg can have a signifi cant impact on a patient’s recovery potential and quality of life. Chapter 8 provides guidelines for choosing the appropriate level of amputation and gives a detailed description of several common amputations. The part on venous disease includes chapters on deep and superfi cial venous thrombosis, chronic venous insuffi ciency, varicose veins, and inferior vena cava (IVC) fi lter placement. Acute deep venous thrombosis (DVT) poses an immediate life threatening problem if it becomes a pulmonary embolism (PE) and a long term disability risk if it causes venous dysfunction. Chapter 9 discusses the medical, endovascular, and surgical treatment modalities for acute DVT which are aimed at minimizing the short and long term clinical impact of venous thrombosis. Rarely, anti-coagulation failure or contraindication warrants placement of an IVC fi lter to reduce the risk of pulmonary embolism. Chapter 13 outlines the indications and risks associated with IVC fi lters and describes the technical aspects of placing and retrieving IVC fi lters. Superfi cial venous thrombosis (SVT) can complicate intravenous access and may become an important clinical problem with the increasing use of peripherally inserted central catheters (PICC lines). Chapter 1 0 provides practical guidelines for recognizing and managing SVT. Chronic venous disease encompasses a wide spectrum of clinical disorders ranging from spider veins to non-healing venous ulcers. Chapter 1 1 focuses on the pathophysiology and non- interventional treatment strategies for chronic venous insuffi ciency while Chap. 1 2 describes various techniques for treatment of varicose veins and superfi cial venous insuffi ciency. T he part on vascular trauma emphasizes surgical intervention for blood vessel injuries that occur in the neck, abdomen, and extremity. Modern management of vascular neck trauma incorporates the injury location, hemodynamic status of the patient, and imaging results. Chapter 14 describes the surgical approach and technical details involved in repairing arterial and venous injuries in each anatomic zone of the neck. Abdominal vascular injuries often prove to be fatal without prompt surgical exposure and effective vascular control. Chapter 1 5 illustrates and explains the maneuvers necessary to isolate, clamp, and repair the major abdom- inal vessels. Extremity vascular trauma poses an ischemic and hemorrhagic risk which may require immediate revascularization or temporary stabilization followed by delayed defi nitive repair. Chapter 1 6 reviews the management of extremity vascular injury including anatomic exposures, the use of tourniquets and shunts, and revascularization principles. All surgeons regularly encounter patients with vascular access issues. Nearly half a million people receive hemodialysis in the USA, and most critically ill patients require some form of central venous access. Chapter 1 7 provides an overview of venous access options and describes insertion techniques aimed at maximizing safety and effi ciency. Establishing and maintaining hemodialysis access can be a challenging undertaking that requires planning, persistence, and technical skill. Chapter 1 8 illustrates and explains the most common arterio- venous access procedures while Chap. 1 9 focuses on the recognition and management of vascular access complications. Preface vii The fi nal part covers a wide range of vascular topics that are associated with more c omplicated clinical issues. These chapters provide a broad overview of the diagnosis and treatment principles for vascular conditions that usually warrant referral to a vascular specialist. Chapter 2 0 summa- rizes the most recent data and guidelines for managing patients with carotid, renal, and mesen- teric stenosis. Chapter 2 1 describes the surgical and endovascular treatment options for aortic pathology including dissections, aneurysms, and traumatic transections. Non- atherosclerotic diseases often pose a diagnostic challenge because of their rarity and unusual clinical manifesta- tions. Chapter 22 provides a well-organized and concise reference for evaluating patients with hypercoaguable disorders, vasculitis, and other uncommon conditions. All surgeons caring for vascular patients must be prepared to recognize and treat hemorrhagic and infectious complica- tions. Chapter 2 3 uses clear treatment algorithms to explain the management of common compli- cations associated with vascular surgery and endovascular interventions. Approximately 75 % of general surgery residents plan to pursue fellowship training in one of a dozen or more clinical areas [2]. Despite this trend toward subspecialization, general sur- geons still derive benefi t from their training and experience in vascular surgery. The ability to control bleeding, restore perfusion, establish vascular access, and manage the increasing nu mber of patients with atherosclerotic and venous disease remain valuable skills for general surgeons. Practicing surgeons and surgical trainees can now turn to this book as a concise and clinically oriented information source for vascular surgery. Syracuse, NY, USA Vivian Gahtan, MD, FACS Michael J. Costanza, MD, FACS References 1 . Valentine JR, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007–2009: A 10 year update from the American Board of Surgery. Ann Surg. 2011;254:520–6. 2. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellow- ships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206:782–8. Contents Part I Basics of Vascular Surgery 1 Diagnosis and Imaging ............................................................................................ 3 Ali F. AbuRahma and Patrick A. Stone 2 Surgical and Endovascular Technique and Tools ................................................. 25 Eanas S. Yassa and Jeffrey P. Carpenter Part II Acute Arterial Disease 3 Peripheral Arterial Thrombosis/Emboli ................................................................ 47 Amy B. Reed and Faisal Aziz 4 Compartment Syndrome ......................................................................................... 55 Col (ret) Mark W. Bowyer 5 Diabetic Foot Infection ............................................................................................ 71 Richard F. Neville, Afsoon D. Roberts, and Gary L. Simon Part III Chronic Arterial Disease 6 PAD and Claudication ............................................................................................. 85 Hasan Haldun Dosluoglu and Purandath Lall 7 Critical Limb Ischemia ............................................................................................ 101 Michael A. Golden and Brant W. Ullery 8 Lower Extremity Amputations ............................................................................... 119 Jason T. Chiriano and Ahmed M. Abou-Zamzam Jr. Part IV Venous Disease 9 Deep Venous Thrombosis ........................................................................................ 135 Anthony J. Comerota and Hussein Barayan 10 Superfi cial Thrombophlebitis ................................................................................. 151 Anil Hingorani and Enrico Ascher 11 Chronic Venous Insuffi ciency .................................................................................. 157 Kathleen J. Ozsvath 12 Varicose Veins ........................................................................................................... 167 Jennifer A. Heller 13 Inferior Vena Cava Filters ....................................................................................... 183 Misaki M. Kiguchi and Ellen D. Dillavou ix