SX Vas

VASCULAR SURGERY
,
50202
II
VASCULAR SURGERY

,
50202
2542
. ..
1. SURGERY
I. ..
II. ..
III. Title [DNLM: 1. Surgery
Vascular. WG 170 V 3311, 1999
ISBN 974-565-871-5
..
III
VASCULAR SURGERY
, ,

.. 2539

IV

72

..., .., (),
.. ( ), F.I.C.S., F.R.C.S.T.,
Cert. in Vascular Surgery (U. of Colorado, U.S.A.)

,
50202
12 2497
VASCULAR SURGERY
I.
1 , ..........................................................3
2 ....................................................................9
3 .............................................................................................. 37
4 .......................................................................................................................... 43
5 Antibiotics in Vascular Surgery ....................................................................................................... 53
6 Noninvasive Vascular Studies .......................................................................................................... 59
7 ........................................................................... 71
8 ............................................................................................................ 81
9 .......................................................................................................... 90
VI
II
91
10 Cerebrovascular disease ................................................................................................................... 93

11 .......................................................................................................................................... 107
12 Abdominal Aortic Aneurysm (AAA)........................................................................................... 115
13 Aortoiliac Occlusive Disease (AIOD) ........................................................................................ 127
14 Intermittent Claudication (IC) .................................................. 137
15 ................................................................................. 143
16 Renovascular Disease ...................................................................................................................... 149
17 Femoro-Popliteal-Tibioperoneal Occlusive Disease.......................................................... 159
18 Buergers Disease (Thromboangiitis Obliterans)................................................................ 167
19 Takayasus Arteritis............................................................................................................................ 173
20 Acute Arterial Occlusion ................................................................................................................. 177
21 Infected Aneurysm ............................................................................................................................. 189
22 The Diabetic Foot............................................................................................................................... 199
III
207
23 Surgical Treatment of Vericose Veins ....................................................................................... 209

24 Venous Thrombosis............................................................................................................................ 221
25 .......................................................................................................................... 231
VII
VASCULAR SURGERY
IV
247
26 .......................................................................................... 249
27 ........................................................................................................... 253
28 Hemodialysis Access ........................................................................................................................ 261
29 ................................................................................................................................. 273
30 .................................................................................. 291
31 Lumbar Sympathectomy ................................................................................................................. 299
VIII

72
1
2
3
4
5
6
7
8
9

Antibiotics in Vascular Surgery
Noninvasive Vascular Studies

800
Srushuta

cauterize bleeding(1-5) 2 Antyllus
aneurysm
content

thrombosis (1,3,5)

35
20
(3,6)
1.
2.
3.

.. 1902 Alexis Carrel Charles Guthrie

triangulation
(7)
1.

2. adventitia

3.
4. three stay sutures triangulation
5.
6. intimal surface
everting suture
Robert Matas (.. 1888-1940)

620 80 15
(6)
autogenous vein graft
.. 1906 1907 Goyanes Lexor. (8,9)
abdominal aortic aneurysm (AAA)
human homograft Gross
.. 1951 1952
4
.. 1952(10)

96 13
2

49
Mobile Army Surgical Hospital (MASH units)

Vietnam Vascular Registry
1,000

13
anticoagulants
, ,
atherosclerosis
1. Arteriography/ Angiography .. 1929
water soluble organic iodides

.. 1927 translumbar aortic puncture ..
1929 percutaneous arterial catheterization
.. 1953

2.
anticoagulants heparin
.. 1937 deep vein thrombosis(11)

dicurmarol (Coumadin)
heparin
Low
Molecular Weight Heparin (LMWH)

3.
anticoagulants
graft failure
4.

aneurysm
atherosclerosis
monitor

ARTERIAL SURGERY
.. 1938 Gross
PDA .. 1944 Blalock
& Tausig Tetralogy of Fallot left
subclavian artery pulmonary artery end-toside anastomosis.
Stockholm Coarctation of the aorta
noninvasive diagnosis ultrasound ultrasonic duplex scanning
digital subtraction angiography

magnetic resonance arteriography (MRA) direction of blood flow

Occlusive and aneurysmal lesions

Gross arterial transplantation
.. 1940 .. 1951 Dubost aneurysmal
sac AAA homograft
Vinyon-N Voorhees .. 1949(12,13)

polytetra-fluoroethylene (PTFE)

Thromboendarterectomy
.. 1946 J Cid dos Santos thrombectomy
heparin thrombectomy
intima inner media
carotid arterial occlusion AIOD
segment localized
The bypass principle

.. 1931 Ernst Jeger
bypass procedure aneurysm ..
1948 excising lesion
.. 1948 J. Kunlin saphenous vein graft
end-to-side anastomosis

collaterals(8) .. 1950 Robert Linton
Massachusetes General Hospital reversed saphenous vein graft arterial conduit
reconstructive bypass.
Arterial embolectomy
.. 1911
suction
heparin (11)
.. 1963 Thomas J. Fogarty balloon tipped
catheter

Aortic Aneurysm Resection

Aortoiliac bypass
AAA Antyllus
aneurysm clot
aneurysmal sac .. 1888 Matas endo-
aneurysmorrhaphy cellophane electro coagulation .. 1951 Rene

Dubost modern repair of AAA .. 1957
DeBakey Knitted Dacron graft aorta
aneurysmorrhaphy
Dissecting Aneurysm
Gorin .. 1935 Shaw .. 1955
dissecting aneurysm fenestration 2
.. 1956 De Bakey
dissecting aneurysm

Carotid endarterectomy
cerebral arteriography
carotid artery
.. 1951 Carrea carotid Debakey .. 1953 Eastcott
.. 1954 carotid endarterectomy
carotid artery 70-99
carotid endarterectomy stroke
Femoro-popliteal bypass
.. 1948 Kunlin
popliteal
Extra-anatomic bypass
.. 1952 Freeman Leeds
superficial femoral artery bypass Blaisdell Hall
extra cavitary bypass axillary artery common femoral artery
aorto - femoral bypass
underlying critically ill

diseases
extra-anatomic bypass alternative procedures intrathoracic intramediastinal procedures occlusive disease aortic arch
ARTERIOVENOUS FISTULA
Guido Guidi (.. 1500-1559) congenital AVM traumatic AVM
Vascular access for dialysis

.. 1943 William Koff
Quinton,
Scribner Dillard .. 1960 shunt
dialysis teflon
3-6 thrombosis
Appel .. 1966 surgically produced AVF
Brescia- Cimino fistula cephalic
vein radial artery
procedure of
choice long term dialysis access
bridging graft

AVF

VENOUS SURGERY
Venous interruption
Virchow (.. 1846-1856)
thromboembolism Virchows triad stasis,
hypercoagulability endothelial injury Bottini ..
1906 IVC interruption postoperative pulmonary embolism
.. 1934 Homan IVC ligation

pulmonary embolism femoral vein
14
chronic venous insufficiency 33
IVC plication
Dale external vena caval clip
.. 1960 intraluminal devices
Green field filter femoral
jugular veins

Ligation and stripping of

varicose veins

.. 370 Hippocrates
.. 200 Galen stab avulsion
greater saphenous vein stripping
1844 Madelung Travel .. 1900
vein ligation sclerotherapy .. 1906 Mayo
extraluminal method vein stripping
Babcock plastic intraluminal vein strippers
100
SYMPATHECTOMY
sympathectomy
Julio Diez
lumbar sympathectomy 1924 ..
1899 Jaboulay Rene Leriche arterial
adventitia periarterial sympathectomy
leg ulcer
.. 1914 Kramer
Todd
revascularization procedures
sympathectomy periph-
eral vasospasm occlusive disease

revascularize sympathectomy
sympathetic activity
regeneration preganglionic fibers accessory ganglions.

Syme .. 1842
syme amputation transmetatarsal amputation
.. 1949

,

1
5
80 - 120

Thai
Vascular Society (TVS) .. 1996 ..
..

vascular anastomosis
200
16
.. 1961 - 1970

.. 1970
The Society of Vascular Surgery The International Society for Cardiovascular Surgery

American Board of Surgery
Vascular Surgery
1
.. 1972 10

The American Board of

General Vascular Surgery
American Board of Surgery

noninvasive diagnosis

1. angiogram
2.
3.

4.

5.

5

AMPUTATIONS
noninvasive diagnotic procedures

less invasive surgery techniques
..
1980 - 1990 laser
balloon angioplasty
Endovascular grafting AAA
..
1991 Parodi stent femoral artery
William Edward Jr. endovascular grafting

AAA Nashville, Tenn. Vanderbilt
St. Thomas Annals of Surgery, May 1996.
Interventional radiology
balloon tipped catheter (Dotter
Gruntzig .. 1974) percutaneous
transluminal angioplasty (PTA) laser
intimal hyperplasia early restenosis
laser
angioscope
1. Dale WA. The beginnings of vascular surgery. Surgery 1974;76:84956.

2. Barker W. A history of vascular surgery. In: Moore WS (ed.).
Vascular Surgery: A comprehensive review. Philadelphia: WB
Saunders, 1993;1-15.
3. Haimovici H. An historic overview of vascular surgery: Past record
and new trends - a vision for the 1990 S. In: Haimovici H. (ed.).
Vascular Surgery: Principles and techniques. Cambridge: Blackwell
Science, 1996;1-10.
4. Friedman SG. A history of vascular surgery. New York: Futura
Publishing, 1989.
5. Wilson S, Veith FJ, Hobson RW, Williams RA. Vascular Surgery:
Principles and practice. New York: McGraw-Hill, 1994.
6. Smith LL. Surgeons and the evolution of vascular surgery. Archives
of Surgery 1993;128:957-63.
7. Ewards WS, Edward PD. Alexis Carrel: Visionary Surgeon. Charles

C. Thomas. Springfield. Illinois 1974.
8. Kunlin J, Treatment of arterial ischemia by long vein grafts. Rev
Chir 1951;70:206-13.
9. Dale WA, DeWeese JA, Scott WJM. Autologous venous shunt
grafts: Rationale and report of 31 for atherosclerosis. Surgery
1959;46:145-55.
10. Hughes CW. Arterial repair during the Korean War. Ann Surg
1958;147:555-66.
11. Murray G. Heparin in surgical treatment of blood vessels. Arch
Surg 1940;40:307.
12. Voorhees AB, Jaretski A, Blakemore AH. The use of tubes constructed from Vinyon-N-cloth in bridging arterial defects. Ann
Surg 1952;135:332-341.
13. Smith RB. Arthur B. Voorhees, Jr., pioneer vascular surgeon. J
Vasc Surg 1993;18:341-47.
I. (
2.1 2.2)
1.1

2.1

vascular angle
venous filling

capillary refilling time

bruits

reactive hyperemic time
(purple-blue cyanosis)

Vascular angle Buergers angle

90o
10
2.2
?
1. angina pectoris,

2. claudication ?
? ischemic rest pain
(impotence)
3. transient ischemic attack (T.I.A) stroke
4. ? ?
5. ? ? ?
6. ?
?
7. ? deep
vein thrombosis (DVT) pulmonary embolism
?
8.
15-30o vascular angle 20o

( 2.1)
1.
2. = 0, = +1,
= +2, = +3, aneurysm = +4
CAROTID RADIAL FEMORAL POPLITEAL D.PEDIS POST.
TIBIAL
BRUIT
3.
4. perfusion, varicosities, trophic changes, ,
5. abdominal aortic aneurysm (AAA)

6. ankle/ brachial index (ABI)
Capillary filling time vascular angle

capillary filling time 15-30

Buergers test ( 2.2)
2.1 vascular angle Buergers angle
11
2.2 Buergers test
.
. reactive hyperemia
Venous filling

(guttering of the veins) ( 2.3)

10-15o

Pressure areas

trophic changes

( 2.4)
2.3
2.4 pressure area
trophic changes
(gutter
ing of the veins)
metatarsal head
(brittle nail)
12
1.2

5

Capillary refilling
2

2

radial, femoral, brachial
popliteal, dorsalis pedis, posterior tibial, carotid
( 2.5)
Femoral pulse
symphysis pubis anterior superior iliac
spine
atherosclerosis

Dorsalis pedis pulse

medial malleoli metatarsal
1 2 pedal pulse
10
2.5
13
2.6 popliteal
pulse
Popliteal pulse

( 2.6)
135o
tibial tuberosities

popliteal fossa
tibia
popliteal
(
2.7) +3
aneurysm, +2 , +1 0

Ankle Pressure Index

sphygmo cuff
brachial doppler probe
45o cuff

brachial systolic pressure
2.7
bruit
14
dorsalis pedis posterior tibial
sphyg cuff
posterior tibial
doppler probe

ankle systolic pressure
ANKLE PRESSURE INDEX (ABI)
ankle pressure brachial pressure
ABI 1
Allen test radial ulnar artery

radial ulnar artery 3
ulnar artery

radial artery
2.8 ANKLE-BRANCHIAL
PRESSURE
1.3
diaphragm

bruit turbulent flow

dorsalis pedis posterior
tibial blood pressure cuff (
2.8) doppler ultrasound

ankle branchial index (ABI)
Reactive hyperemia test

blood pressure cuff 250
3
hyperemia flushing
1-2
2
Exercise test

ABI

ABI
ABI

15
II.
2.1 INTERMITTENT CLAUDICATION (IC)

50
embolism Buergers disease,
Takayasus disease

aortoiliac (impotence)
intermittent claudication

1.
2.
3.

claudication

claudication cramping pain
(claudication time)
(claudication distant)
(numbness)
metabolic
waste products

night
cramp

16
aortoiliac
claudication
calf claudication

neurospinal canal lumbar
aortoiliac occlusive
disease (AIOD)

AOID
venous claudication
iliofemoral thrombus
collaterals recanalization
arterial inflow venous outflow

(bursting pain)

Buergers disease
arteriosclerosis drawing cramping pain

vascular angle
(
2.9)
venous filling

ankle brachial ratio

(sciatica)
2.9

2.2 ISCHEMIC REST PAIN

claudication pain

60

Buergers disease

malleoli
ischemic ulcer

cardiac
output

Phantom
limb sign
ischemic rest
pain intermettent claudication
angina
stroke

17

bruit

(marble like)
(vascular angle) 20o

atrophic change pressure area

capillary refilling
doppler ultrasound bruit

disuse atrophy flexion deformity

2.3 PREGANGRENE AND GANGRENE

Pregangrene

pregangrene rest pain
2.2
rest pain

Gangrene
( 2.10)

18
2.10 ischemic rest pain

dry gangrene

line of demarcation
(autoamputation) line of demarcation
ischemic rest pain
line of demarcation
wet gangrene
2.4 ISCHEMIC ULCERATION

ischemic
rest pain

ischemic ulcer 2.3
atherosclerosis, scleredema, , , Buergers disease, , ,

ischemic ulcer

punch out lesion

granulation tissue

19
2.3 ISCHEMIC ULCERATION
atherosclerosis
embolism
Raynauds disease
Scleredema
Embolism

reflexed
ischemic ulcer
sensory neuropathy (
2.4, 2.5)
2.5 NEUROPATHIC ULCERATION

2.5
:

discharge
:

neurotrophic ulcer

ischemic ulcer

neurotrophic ulcer ( 2.6)
1.
2.
3.

ischemic ulcer

neurotrophic ulcer
1.

2.6 neurotrophic ulcers
2.4
spina bifida
tabes dorsalis
syringomyelia
20
2. spina bifida, tabes

dorsalis, syringomyelia
ischemic ulcer
atherosclerosis

2.6 OCCLUSIVE PERIPHERAL VASCULAR

DISEASES
2.6.1 THE LERICHES SYNDROME
femoral

thrombus
iliac
aorta
2.6.2 THROMBOANGITIS OBLITERAN Buergers
disease
50

Buergers disease (inflamumatory phase) superficial migratory thrombophlebitis
2.6.3 COARCTATION OF THE AORTA

aorta
subclavian ductus arteriosus coarctation of the aorta
patent
ductus arteriosus
cerebro vascular accident (CVA)

collaterals
systolic murmur
left vertebral column T4 T5
2.6.4 CEREBROVASCULAR INSUFFICIENCY

transient
neurologic deficit transient ischemic attack
24
(amaurosis fugax)

vertebrobasilar insufficiency
(VBI) VBI
CVA
microemboli
retina
visual field opthalmoscope
fundi
microemboli
yellow-white exudate

, disseminated sclerosis, temporal arteritis
subclavian
clavicle vertebral bruit
innominate subclavian
collaterals

cerebrovascular insufficiency arteriosclerosis fibromuscular hyperplasia
carotid Takayasus artertis
2.6.5 GASTROINTESTINAL ISCHEMIA
15-30
abdominal angina

bruit xiphoid

celiac
trunk superior mesenteric artery
arteriography
acute
intestinal infraction
2.6.6 SUBCLAVIAN STEAL SYNDROME
subclavian
vertebral artery

systolic murmur
common carotid artery
retrograde vertebral flow (the circle of Willis anastomosis) radial
( Javid)
50
2.6.7 COSTOCLAVICULAR SYNDROME
clavicle
( trapezius, sternocleidomastoid, levator scapulae)
subclavian clavicle

2.6.8 CERVICAL RIB SYNDROME 0.4%

7

cyanosis
mocroemboli subclavian

scalenus
anticus radial subclavian artery murmur
subclavian thoracic outlet supraclavicular fossa
21
cervical rib
2.6.9 RAYNAUDS PHENOMENON

WBC
W=white, B=blue, C=crimson red

deoxygenated blood
venous congestion
(reactive hyperemia)
2.7 RAYNAUDS PHENOMENON

cervical spondylosis cervical disc protusion

cervical ribs
thoracic outlet syndrome
spinal cord diseases
poliomyelitis
:
subclavian aneurysm ( cervical rib)
subclavian
subclavian
cervical rib, collagen disease
Collagen disease
scleredema

cold aggluti
nin, cryoglobulin
cold sensitivity (primary Raynauds disease)
ergot
hypothyroidism, ,
22

Raynauds phenomenon

( 2.7) cervical spondylosis, scleredema,
cervical rib idiopathic Raynauds disease

cervical spondylosis, scleredema cervical rib
Raynauds phenomenon
digital artery emboli

ischemic ulcer
paronychia
ischemic rest pain

primary Raynauds disease
(teenage)

20

20
primary Raynauds disease sclerederma
2.6.10 ACROCYANOSIS

Raynauds disease

2.6.11 ERYTHROMELALGIA

flushing,

2.6.12 LIVEDO RETICULARIS
primary livedo reticularis

secondary livedo reticularis

2.7 ACUTE ARTERIAL OCCLUSION

arterial thrombosis, embolism
2.7.1 ACUTE ARTERIAL THROMBOSIS

thrombus
femoral artery
subsartorial canal
thrombus
embolism intermittent claudication
collaterals
thrombus

atherosclerosis

acute arterial thrombosis
2.7.2 EMBOLISM
atrial fibrillation,
90 mural thrombus
aneurysm aorta
embolism

23
collaterals (numbness)

1-2
(mottling) 5P
Pulselessness, Pallor, Pain, Poikilothermia, Paresthesia
2.7.3 TRAUMA

intima

supracondylar fracture of the shaft of the humerus
dislocation of the shoulder
supracondylar or shaft fracture of the femur
dislocation of the elbow
dislocation of the knee
2.8 (aneurysm)
embolism

2.8 ANEURYSMAL DISEASE

aneurysm
1 1/2
( 2.11)
congenital aneurysm berry aneurysm
arteriovenous fistula acquired aneurysm
degenerative disease
( 2.8) false aneurysm

atherosclerotic aneurysm aorta femoral popliteal
50 ( 2.12)
I. TRUE ANEURYSMS
Congenital : weak areas (berry aneurysm)

weak walls (Marfans syndrome,
Ehlers-Danlos syndrome)
congenital arteriovenous fistula

Acquired : Trauma:
Infection: non-specific bacterial

arteritis (mycotic), syphilis
Degeneration: atherosclerosis,
arteriomegaly, cystic medionecrosis
II. FALSE ANEURYSMS
2.11
. Fusiform aneurysm
. Saccular aneurysm
. False aneurysm

24
2.13 De Bakeys sign AAA

2.12 aneurysms
Renal arteries
aneurysm costal margin
abdominal aortic aneurysm (AAA)

( 2.13)

(valve)

( 2.9)
( 2.14)

2.14
25
2.9

?
?

Trendelenberg test
Tourniquet test
wave conduction
bruits

venous stars

saphenofemoral
junction cough impulse
competency
( 2.15) communicating
veins deep superficial veins (
2.16)
(brown pigmentation)

2.15 competency saphenous vein

watching finger
tapping finger
tapping test for saphenous incompetence
2.16 venous ulcers brawny induration

chronic venous insufficiency
26
I. VENOUS THROMBOSIS
Thrombosis (deep)
(superficial) 25-40
thrombus

pulmonary embolism
deep vein thrombosis

venous thrombosis
40
femur

deep vein thrombosis (DVT)

thrombus
emboli

dorsiflex
posterior tibial vein thrombus
Homans sign

thrombus
Achillis tendon
thrombus soleus
soleus plexus thrombosis
thrombosis
posterior tibial popliteal
space saphenous opening inguinal ligament

1.1 ACUTE VENOUS THROMBOSIS

1.1.1 Phlegmasia Alba Dolens (whiteleg, milkleg)
thrombus iliofemoral

thrombus soleus plexus
femoral

12
femoral
iliac fossa acute
phase 2-6
chronic phase

venous ulcer
1.1.2 Phlegmasia Cerulea Dolens thrombus ileofemoral

venous gangrene
reflex
spasm

venous thrombectomy

1.1.3 Superficial thrombophlebitis
thrombus

Buergers disease, polycythemia, polyarthritis
( 2.10)

27
2.10 superficial thrombophlebitis

Varicose veins
Occult carcinoma: bronchus, pancreas, stomach,
lymphoma
Thromboangiitis obliterans (Buergers disease)
Polycythemia
Polyarteritis
Idiopathic
Iatrogenic:
1.1.4 Thrombophebitis migrans

sinister sign occult malignancy
superficial migratory
thrombophlebitis Trousscans sign
Buergers disease
1.1.5 Mandors disease string phlebitis
1.2 CHRONIC VENOUS INSUFFICIENCY

cellulitis fibrosis
( 2.11, 2.12)
DVT

venous claudication
brawny edema fibrosis
(venous hypertension)
hydorstatic pressure
hemosiderin pigment
oxidation
2.11
Pain
Location
Bleeding with manipulation

Characteristics
Associated findings
ISCHEMIC
STASIS
NEUROPATHIC
Severe,particularly
night,relieved by
dependency
Distally,on dorsum
of the feet or toes
Mild,relieved by
elevation
None
Lower 1/3 of leg

(gaiter area)
Under calluses or
pressure points (Plantar
aspiects of 1st+5th metaphalangeal joints)
May be brisk
Punched out with deep
sinus
Demonstrable
neuropathy
Little or none
Irregular edge,
poor granulation tissue
Trophic changes
of chronic ischemia
Venous ooze
Shallow,irregular
shape,granulating edges,
Stasis dermatitis
28
2.12
Consistency of
swelling
Relief by
elevation
Distribution of
swelling
Pain
Bilaterally
VENOUS
LYMPHATIC
ORTHOSTATIC
CARDIAC/
LIPIDEMA
Brawny
(fat)
Complete
Spongy
Pitting
Non-compressible
Mild
Complete
Minimal
Diffused,
greatest
distally
None or
heave ache
Diffused, greatest
distally
Maximal in ankles,
and legs, feet
spared
Dull ache,
cutaneous sensitivity
As often as
not
Always but may

be unequal
Maximal, in
ankles and leg,
feet spared
Heavy ache,
tight or
bursting
Occasionally,
but usually
unequal

(brownish skin pigmentation) ( 2.16)
fat
necrosis fibrosis
inverted champagne bottle ( 2.16) venous stasis ulcer
gaiter area

2.13
Primary

Secondary :
, , ascites,
iliac vein thrombosis, ,
retroperitoneal fibrosis
: deep vein thrombosis
:
arteriovenous fistula
Little or none
Always

( 2.14)

2.14
Secondary
Neoplastic infiltration of lymph nodes:
Secondary carcinoma
Primary reticuloses
Infection:
Filariasis
Lymphogranuloma inguinale
Tuberculosis
Recurrent non-specific infection
Iatrogenic
Surgical excision and
Irradiation of lymph nodes
Primary
Congenital or acquired deficiency of the lymphatics
Dilatation and incompetence of the lymphatics
29
cellulitis
vascular granulation tissue epithelium
squamous cell (Marjolins ulcer)
1.3 VARICOSE VEINS

long
short saphenous veins
deep
veins perforating veins deep fascia long
saphenous vein perforators 3 ( 2.17)
subsatorial canal
3 3 incompetent valves

perforators
flare sign

10

night
cramp
venous stars, ,

( 2.13)

short saphenous vein

venous hypertension
(brown pigmentation)
(gaiter area)
long short saphenous veins

2.17 perforating veins

Cough impulse test competency
long saphenous vein saphenofemoral
junction saphenous opening
fluid thrill
incompetent valve
Trendelenberg test (retrograde filling)
competency
saphenofemoral veins
(torniquet)
venous filling venous
filling 35
( 2.18)
capillary
beds venules
1. filling superficial veins
incompetent
valves perforators deep
veins superficial veins
2. filling superficial veins
incompetent valves saphenous veins
( 2.19)
30
2.18
The Brodie-Trendelenbug
test for venous valvular incompetence
1.
2.
3.
4.
-, -ve
-, +ve
+, -ve
+, +ve
incompetent saphenofemoral valve

incompetent perforators
incompetent perforators
saphenofemoral valve
Torniquet test incompetent valves
2.19 Brodie-Trendelenberg test
pertorator
1/3
( 2.20)
incompetency perforators

incompetency perforators

perforator incompetent
Fegans method
incompent perforators
perforators
perforators
saphenous vein

Trendelenberg torniquet test

incompetency
saphenous vein transmitted wave

doppler ultrasound
arteriovenous malformation

31
2.20 Torniquet test
1.4 VENA CAVA

1.4.1 superior vena cava (SVC)

(engorgement)
( 2.21) thrombus
SVC

(blood shed eyes)
2.21 SVC syndrome
venous star

-
,
sarcoidosis, aneurysm of the aortic arch, idiopathic
mediastinitis, substernal goiter

1.4.2 inferior vena cava (IVC)

collaterals

collaterals
IVC portal vein
collaterals
superficial collaterals
2

IVC portal vein (Harveys test) IVC
50-60
retroperitoneal fibrosis,
, lipomatosis, abdominal aortic
aneurysm
32
1.5
2 multiple arteriovenous
fistula
1.5.1 multiple arteriovenous fistula (Robertsons
giant limb)

cardiac output (CO)

venous ulcer
venous hypertension stasis change

Branhams bradycardia response
1.5.2 venous abnormalities (Klippel-Trenaunay syndrome)

1.
2. cutaneous angiomata port wine stains
3.
arteriovenous fistula
bradycardia test
(THE LYMPHATICS)

severe lymphedema mild lymphedema
( 2.22)
(tendo achillis con-
tour)
cobble stone

8 interdigital cleft
8 medial
melleolus
12 lower border
of patella
12 upper border
of patella
1. (lymphangitis)

(throbbing pain)

cellulitis
2. (lymphedema)
interstitial tissue

( 2.14)

33
2.22 .
. tendo Achillis
( 2.15)
1o lymphedema
2o lymphedema
2o lymphedema

Filariasis Wuchereria
bancrofti

1o lymphedema
3-4

atheletes foot tinea pedis

cellulitis
septicemia 1o lymphedema
(familial disease)

hyperkeratosis
lymphedema
(general
causes) (local cause)

34
2.15 Primary lymphedema
2.16
Primary lymphedema
1. lymphedema
2. lymphedema precox
3. lymphedema tarda 35
Infection
Non-specific
Glandular fever
Tuberculosis
Toxoplasmosis
Syphilis
Cat scratch fever
Filariasis
Lymphogranuloma (inguinale)
Metastatic tumor
Primary reticulosis
Sarcoidosis

1o lymphedema

3. POSTMASTECTOMY EDEMA

axillary nodes
2-3 axillary vein

thrombosis 1-2
axillary
vein

4. LYMPHANGIOMA
(
)

fluctuation transilluminate
cystic hygroma
5. (LYMPHADENOPATHY)

( 2.16)
35
1. Pousti TJ, Wilson SE, Williams RA. Clinical examination of the

vascular system. In: Veith FJ (eds). Vascular Surgery. Principles
and Practice. 2nd ed. New York: McGraw. Hill; 1994;74-89.
2. Browse NL. The arteries, veins and lymphatics. In: Browse NL ed.
Introduction to Symptoms and Signs of Surgical Disease, 2nd ed.
London: Edward Arnold, 1991;159-192.
3. Vascular Disorder. In:Burkitt HG, Quick CRG, Gatt D. (eds). Essential Surgery. Problems, and management. Edinburgh: ChurchillLivingston, 1990;483-536.
4. Rutherford RB. The surgical approach for Vascular Problems. In:

Rutherford RB(eds). Vascular Surgery 4th ed. Philadelphia: WB
Saunders, 1995;1-16.
5. Calligaro KD, Veith FJ. Proper technique of lower extremity pulse
examination. Contemp Surg 1992;40:49-51.
6. Veith FJ, Gupta SK, Wengerter KR, et al. Changing arteriosclerotic
disease patterns and management strategies in lower-limb threatening ischemia. Ann Surg 1990;212:402-412.
7. Abramson DI. Symptoms and signs of arterial vascular disorders.
Surg Clin North Am 1960;40:3-14.
36
30

atherosclerosis, aneurysm,

intima
vasa vasorum external elastic membrance
3. adventitia

Intima-endothelial cells
(arteries)
( 3.1)
1. intima

longitudinal media internal elastic
membrance
2. media

circumferential
Lumen
Internal elastic membrane

Media
-Smooth muscle cells
-Collagen
-Elastin
-Proteoglycans
Adventitia
-Fibroblasts
-Collagen
-Elastin
External elastic membrane
Vasa vasorum
3.1 cross-section anatomy of an artery
38

3 intima, media
adventitia

greater saphenous
vein media

2.5
(valve)

intima

extravascular environment 0.2
3 intima, media adventitia

atherosclerosis thrombosis
ATHEROSCLEROSIS

atherosclerosis

atherosclerosis
(1)
1.

2.

3.

4. shearing force

5.
6.
atherosclerosis

(fixed point) shearing force turbulent flow
atherosclerosis
aorta aortic bifurcation, common
iliac bifurcation, common femoral bifurcation, common
carotid bifucation superficial femoral artery (SFA)
Hunters canal fixed point ( 3.2)
High shear
region
Atherosclerotic
plaque
Low shear
region
3.2
39
atherosclerosis aorta
abdominal aorta vasa vosorum

prostaglandin,

atherosclerosis

1. fattly streaks
cholesterol ester (lipid)
macrophages
2. fibrous plaques

arterial lumen

3. complicated plaques atherosclerosis
fibrous plaques necrosis

atherosclerosis

low density preteins atherogenesis
3.1 ARTERIAL ANEURYSMS

CONGENITAL
Medical agenesis
Marfans syndrome
Ehlers-Danlos syndrome
Genetie defects of elastin and
collagen
INFLAMMATORY Syphilitic
Bacterial
Noninfecteous inflammatory disease
TRAUMATIC
Traumatic aneurysm
Anastomotic (post surgical)
Poststenotic aneurysm
DEGENERATIVE Arteriosclerotic
Fibrodysplasia
1. plaques low density lipoprotein atheromatous lesions

2.

3. familial type II hyperlipidemia atherosclerosis
4.
atherosclerosis
5. atherosclerosis
atherosclerosis

1.
2.
3.
4.
5.
6.
7.
8.
ARTERIAL ANEURYSMS
aneurysm
1.5 (saccular)
(fusiform)
ectasia arteriomegaly
multiple aneurysms arteriomegaly multiple aneurysms

arteriomegaly
aneurysm
3.1
infrarenal abdominal aortic aneurysm (AAA) atherosclerosis
intimal degerative process

40
aortoiliac occlusive disease
atherosclerosis aneurysm(2,3,4)
aneurysm atherogenic diet
30 AAA peripheral arterial occlusive disease AAA
AIOD 10
generalized arteriomegaly aneurysmosis
tunical media elastin, collagen
elastin
aneurysm collagen

AAA
elastin elastin
tunica media elastin
plasma cell intimal medial
thickening occlusive disease
elastin collagen
aorta elastase collagenase
AAA elastase
neutrophils, macrophages pancreatic exocrine cells(5) &-1-trypsin elastolytic inhibitor
AAA COPD

infrarenal AAA infra renal
aorta elastin collagen thoracic
aorta
aorta bifurcation

AAA
inflammatory cells
cytokines AAA inflammatory cells
elastase collagenase
AAA
(6)
INTIMAL HYPERPLASIA

25
thrombosis
(7) bypass graft failure

endarterectomy
progressive atherosclerosis
intimal hyperplasia
intima
growth factors
vessel healing

atherosclerosis

atherosclerosis, aneurysm vasculitis

intimal hyperplasia

growth factors
growth factor intimal hyperplasia atherosclelrosis
41
1. White RA. Atherosclerosis and arteriosclerosis: Human pathology

and experimental animal methods. Boca Ratons, Fla: CRC Press,
1989.
2. Dobrin PB. Pathophysiology and pathogenesis of aortic aneurysm:
Current concepts. Surg Clin North Am 1989;69:687-704.
3. Zarins CK, Glagov S, Vesselinovitch D, et al. Aneuryms formation in
experimental atherosclerosis: Relationship to plaque formation. J
Vasc Surg 1990;12:246-256.
4. Hollier LH, Stanson AW, Gloviczki P, et al. Arteriomegaly: Classification and morbid implications of diffuse aneurysm disease. Surgery 1983;93:700-708.
5. Cohen JR. Role of the neutrophil in abdominal aortic aneurysm
development. Cardiovasc Surg 1993;1:37.
6. Majumder PP. On the inheritance of abdominal aortic aneurysm.
Am J Hum Genet 1991;48:164.
7. Varty K, Allen KE, Bell PRF, et al. Infrainguinal vein graft stenosis.
Br J Surg 1993;80:823-833.
42
1.
(Antiplatelet agents)
1.1 prostaglandin pathway (1)
cyclooxygenase arachidonic acid
prostagladin endoperoxide
thromboxane A2

cyclo-oxygenase prostacyline
cyclo-oxygenase

prostacyclin 3-4
600 2
thromboxane A2
prostacyline ( 4.1)
enteric coated aspirin
325
80
2 (2)

thrombosis

bypass TIA, stroke,
MI(3,4) dipyridamole
(5) femorodistal
bypass 325
graft patency coronary bypass (6)

44
ENDOTHELIAL CELL
PLATELET
Stimulus
Cell Membrane
Cell Membrane
Phospholipids
Phospholipids
Phospholipase
Phospholipase
Arachidonic Acid
Arachidonic Acid
!
!
!
Aspirin
(large dose)
Cyclooxygenase
Cyclooxygenase
(small and
large doses)
Cyclic Endoperoxides
Cyclic Endoperoxides
PGI-2 synthetase
TXA-2 synthetase
Prostacyclin
Thromboxane (TXA-2)
! (-inhibits platelet
cAMP aggregation &
! vasodilation)
!
phosphodiesterase
Persantine
cGMP
(-promotes platelet
aggregation &
vasoconstiction)
Inactive cAMP
4.1 aspirin and Persantine

prostaglandin pathway
1.2 Dipyridamole
phosphodiesterase
cAMP
( 4.1) dipyridamole
thromboxane A2
adenosine

25-50
3-4
bypass
10

, platelet-activating factor,
ADP(7) 125
2 ticlopidine
stroke, MI intermittent claudication
10
placebo(8)
neutropenia, pancytopenia agranulocytosis 2
(9)
1.4 Dextran polysaccharide long-chain CHO
1940 volume expander
1960
thromboembolic disorder 1970(10)
2 dextran 70 (
70,000 ) dextran 40 ( 40,000
) 6% dextran 70 10% dextran 40 5%

dextran plasma volume expansion,

microcirculation
macromolecules
microcirculation dextran electronegative membrance potential
(11)
dextran plasma
fibriolytic activity dextran 70
half-life 24 dextran 40 half-life 6
10% dextran 40

dextran venous thrombosis(12,13)
dextran
small-caliber arterial grafts distal lower
extremity bypass graft dextran 20
1 24 72

DVT pulmonary emboli
(14,15)

dextran

dextran osmotic
damage tubular cells dextran blood typing
cross matching(16,17)
dextran

10 anaphylactic reaction 0.1
dextran 70
dextran 40(18)
1.5 Prostaglandin (PGs) 20-carbon unsaturated
fatty acids
phospholipase
arachidonic acid phospholipid
prostaglandin
end products
end products thromboxane-A.2
PGI-2
cAMP cAMP
TXA-2 cGMP
cGMP

PGI-2 TXA-2
2.
(Anticoagulants)(19)
2.1

45
mast cells

half-life 1 1/2

partial thromboplastin time
(PTT) activated clotting time (ACT)
1.5-2

(coagulation cascades)
( 4.2)
1. prothrombin thrombin
2. antithrombin III
thrombin antithrombin III
cofactor thrombin
3. electronegative
potential
heparin-Induced-Thrombo
cytopenia (HIT)
prolonged PTT ACT neutralized protamine sulfate
1 100

protamine sulfate

osteoporosis
2.2 Low melecular weight heparin (LMWH)

depolymerization standard
unfractionated heparing (UFH) glycoaminoglycan
4,500 anti Xa activity anti IIa activity immediate prolonged antithrombin action
plasma anti-Xa activity
3 half life 3.5 anti-Xa activity 18 thromboembolic disorders

46
4.2 Coumadin, heparin, streptokinase and urokinase coagulation cascade.

fixed dose

thromboembolic disorder 12
ambulate 10
ambulate (20)
monitor PTT
protamine
sulfate 6 0.1 (2,500 ICUAXa)
Fraxiparen ,
NSAIDS, nadroparin ticlopidine
thrombocytopenia, cutaneous necrosis
47

DVT
osteoporosis
fracture spine
teratogenic effect
DVT LMWH
thrombocytopenia osteoporosis unfractionated heparin
2.3 Coumadine (sodium warfarin)

vitamin K dependent factors coagulation cascades ( 4.2) factor II (prothrombin), VII, IX
X vitamin K antagonist
vitamin K dependent factors half-life
3-5

microsomal enzyme syetem

Coumadine half-life 36
1-8 PT
monitor PT
Vitamin K fresh
frozen plasma (FFP)
2.4 Ancrod 37,000
malayan pit viper (Agkistrodon
rhodostoma) circulatory half lift 3-5 Ancrod
A fibrinopeptides (A, AY AP) circulating fibrinogen cross linking
phagocytosis reticuloendothelial system (RES)

rheology Ancrod
(20)

hypofibrinogenemia (21)
0.2-0.6 /
spontaneous thrombosis
70-100 (1-2 / 1
) 12-36
48 12
infusion rate
Ancord
4-6 serum proteinase inhibitor Ancrod
(22)
Ancord Heparin Induced Thrombocytopenia (HIT)

antithrombin III
Ancord strokd, DVT,
pulmonary embolism central retinal thrombosis
hemodialysis, cardio pulmonary bypass

cryoprecipitate
Ancord Ancord
3.
(circulation - enhancing drugs)
3.1 Hemorrheologic drugs
3.1.1 Pentoxifylline theobromide
1930

1973 Hess
hemorrheology
Intermittent claudication
(FDA)
1980
(23)
1. lipophosphoprotein

2.
3.
4.
5. rhelogic characteristic
48
IC 6-8
25-40

30
3.1.2 Dextran
plasma volume expander
electromagnetic carpet

DVT
3.2
(metabolic enhancing agents)
3.2.1 Carnitine

citric acid cycle
ATP
(24)
carnitine
anaerobic
carnitine IC
carnitine

3.2.2 Naftidofuryl (praxilene)

(25-28)
1. 5-HT receptor blockade

2. triboxylic
acid cycle ATP

3.

ATP

IC, ischemic rest pain vasospastic disorders
4. (vasodilators)
peripheral vascular tone
receptors vasoactive hormones norepinephrine, epinephrine

serotonin prostacycline
endothelium-derived relaxation factors flow-induced vasodilatation epinephrine

norepinephrine arteriography

4.1 Tolazolin hydrochloride (Priscoline, Ciba Pharmaceuticals, Edison, NJ)

selective arteriography
portal mesenteric venous opacification arterial portography selective catheterization
25 5-10
20-30
4.2 Nitroglycerine
100-200u
4.3 Papaverine hydrochloride
arteriography local application

4.4 Calcium channel blockers
selective arteriography angioplasty
Nifedipine 10
10-15

reflex tachycardia

49
5. (Fibrinolytic agents)
lating plasmin inhibitors plasmin

(exogenous fibrinolysis) thrombus plasminogen
bounded-plasminogen
plasmin

thrombus-bound plasminogen systemic circulating coenzymes
tissue plasminogen activator (tPA)
melanosma cell lines recombinant DNA
systemic fibrinolysis UK SK(30-33)
5.1 Streptokinase (SK) nonenzymatic protein
Lancefieds group C strain of beta-hemolytic
Streptococci 1933 Tillet Garna

plasminogen 1:1 activator complex streptokinase-plasminogen complex fibrinolytic system
uncomplexed plasminogen plas-
fibrinolytic system ( 4.3)

direct activators indirect activators indirect
activators fibrinolytic activity plasminogen in vivo direct activators fibrinolytic
activity plasminogen in vitro
fibrinolytic activity
tPA antidiuretic hormone

diguanides (Phenformin)
Stanozol (anabolic hormones)
5 fibrinolytic system
(29)
direct fibrinolytic agents plasminogen
plasmin fibrinolytic system fibrinolytic activity
plasminogen lytic action
Urokinase (UK) Streptokinase (SK) circu-
THE FIBRINOLYTIC SYSTEM
Plasminogen
+
+
+
+
- Anti-Activators
- Blood, Tissue
and Urine inhibitors
Fibrinogen
4.3 Fibrinolytic system
Plasmin
Activated Factor XII

Tissue Activator
Urokinase
Streptokinase-->complex
Fibrin
!
+ Thrombin
Inhibitors
Alpha 2 Anti-plasmin
Alpha 2 Mauroglobulin
Alpha 1 Antitrypsin
Antithrombin III
Complement 2 inhibitor
Soluble Fibrin
Split Porducts
50
min SK plasmin
plasminogen
neutralized antistreptococcal
antibodies streptococci
SK circulating plasminogen

half life 2 16 83
1.7-1.8, serum sickness,
leukocytoclastic vasculitis delayed hypersensivity
5.2 Urokinase (UK) direct activator
trypsin-like
serine protease

nonantigenic nonpyrogenic
SK
circulating plasminogen
fibrin- bound plasminogen UK plasminogen proteolysis
half-life 14 UK
fibrinogen fibrinolytic response SK
endogenous lytic activity
SK
plasminogen
5.3 Tissue Plasminogen Activator (tPA) serine

protease
plasminogen activator
tPA
tPA plasminogen
plasmin plasmin
thrombus
tPA circulating plasminogen
plasminogen plasmin
( systemic lytic state) tPA
1940
Bowes melanoma cell lines 1980
direct plasminogen activators fibrin selective
agent(34)
5.4
Acylated Streptokinase Plasminogen Complex (APSAC), Plasmin B-chain Streptokinase Complex, Pro-Urokinase Immunofibrinolysis
51
1. OBrien Jr. Effects of salicylates on human platelets. Lancet

1968;1:779.
2. Turpie AGG. Antiplatelet therapy. Clin Hematol 1981;10:497.
3. Mustard JF, Kinlough-Rathbone RL, Packham MA. Aspirin in the
treatment of cardiovascular disease: A review. Am J Med 1983;74:43.
4. Lewis HD Jr, Davies JW, Archibald DG, et al. Protective effects of
aspirin against acute myocardial infarction and death in men with
unstable angina. N Engl J Med 1983;309:396.
5. Chesebro JH, Fuster V, Elvback LR, et al. Effects on dipyridamole
and aspirin on late vein graft patency after coronary bypass operation. N Engl J Med 1984;310:209.
6. Kohler TR, Kaufman JL, Kacoyanis G, et al. Effects of aspirin and
dipyridamole on expanded PTFE graft patency. Surgery 1982;92:1016.
7. Brun JJ. The mechanism of action of ticlopidine. Thromb Res Suppl
1983;4:59.
8. Gent M, Blakeley JA, Easton JD, et al. The Canadian American
Ticlopidine Study (CATS) in Thromboembolic stroke. Lancet
1989;1:1215.
9. Arcan JC, Blanchard J, Boissel JP, et al. Multicenter double blind
study of Ticlopidine in the treatment of intermittent claudication
and the prevention of its complications. Angiology 1988;39:802.
10. Collins GJ, Bergentz SV. Dextrans. In: Collin G (ed). Vascular Occlusive Disorders: Medical and Surgical management. Mt Kisco, NY,
Futura Publ 1981;393-420.
11. Carin G, Modig J, Saldeen T. Effect of infusion of dextran 70 on
fibrinolysis inhibition activity in human serum. Acta Clin Scand
1979;145:129.
12. Moncrief JA, Darin JC, Canizaro PC, et al. Use of dextran to prevent
arterial and venous thrombosis. Am Surg 1963;158:533.
13. Rothermed JE, Wessinger JB, Stitchfield FE. Dextran 40 and thromboembolism in total hip replacement surgery. Arch Surg 1973;106:135.
14. Bergentz SE, Eikon O, Gelin LE. Rheomacrodex in vascular surgery.
J Cardiovasc Surg 1963;4:388.
15. Rutherford RB, Jones DN, Bergentz SE, et al. The efficiency of
dextran 40 in preventing early postoperative thrombosis following
difficult lower extremity bypass. J Vasc Surg 1984;1:165.
16. Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet 1977;1:466.
17. Gruber UF, Saldeen T, Brokop T, et al. Incidences of fatal postoperative pulmonary embolism after prophylaxis with dextran 70 and
low dose heparin: An international multicenter study. Br Med J
1980;1:69.
18. Thomas JM, Silva J. Dextran 40 in the treatment of peripheral

vascular disease. Arch Surg 1973;106:138.
19. Nussbaum M, Boschos C. Anticoagulants and anticoagulation. Med
Clin North am 1976;60:855.
20. Kappenhagen K, Adolf J, Mattress M. Low molecular weight heparin and prevention of postoperative thrombosis in abdominal surgery. Thromb Hae most 1992;67:627.
21. Cole CW, Bormanis J. Ancord: A practical alternative to heparin. J
Vasc Surg 1988;8:59.
22. Pitney WR, Bray C, Holt P, et al. Acquired resistance to ancord.
Lancet 1969;1:79.
23. Stergachis A, Sheingold S, Luce BR, et al. Medical care and cost
outcomes after Pentoxifylline treatment for peripheral arterial disease. Arch Intern Med 1992;152:1220.
24. Bahl JJ, Bresler RD. The Pharmacology of carnitine. Ann Rev
Pharmacol Toxicol 1987;27:257.
25. Burns JG, Galloway DJ, Ledingham IM. Effect of naftidrofuryl on
the metabolic response of surgery. Br Med J 1981;7:283.
26. Clyne CAC, Gallard RB, Fox MJ, et al. A controlled trial of naftidofuryl
in the treatment of intermittent claudication. Br J Surg 1980;67:347.
27. Greenhalgh RM. Naftidofurly for ischemic rest pain: A controlled
trial. Br J Surg 1981;68:265.
28. Waters KJ, Crawford AD, Chamberlain J. The effect of naftidofuryl
(Praxilene) on intermittent claudication. Br J Surg 1980;67:349.
29. Bell W, Meck A. Guidelines for the use of thrombolytic agents. N
Engl J Med 1979;301:1266.
30. Marder VJ, Sherry S. Thrombolytic therapy: Current status. N Engl
J Med 1988;318:1512.
31. Towne JB, Bandyk DF. Application of thrombolytic therapy in vascular occlusive disease: A surgical view. Am J Surg 1987;154:548.
32. McNamara TO, Bomberger RA, Merchant RF. Intra-arterial urokinase as an initial therapy for acutely ischemic lower limbs. Circulation 1991;83: (suppl):1106.
33. Graor RA, Risuus B, Geisinger MA, et al. Thrombolysis with recombinant human tissue plasminogen activity in patients with peripheral artery and bypass graft occlusion. Circulation 1986;74: (suppl
.1):1-15.
52
5
ANTIBIOTICS IN
VASCULAR SURGERY

carotid endarterectomy
1.1 abdominal aortic resection
2-5(1)
2-3 33-58(2)

aorta

25-75

systemic underlying disease

Staph.aureus

4
(3)
1. (clean wound)
2. (clean contaminated wound)

3. (contaminated wound)
4. (dirty wound)

54
1.8
37(4)

(1,5)

(6,7)
(8,9,10)
1.
2. 2
3.
4. underlying systemic disease

elective
folliculitis furuncles
cellulitis

(11)
toxicity (narrowed
spectrum)
(broad spectrum)
Staph.aureus Staph.epidermidis
(11,12)

taph.aureus, Staph. epidermidis
E.coli Proteus Pseudomonas
33 Steph.aureus, Staph. epidermidis E.coli(2,12) Staph.
epidermidis

75

Povidone iodine
Steri-drape(11)

30
(1)
4 (14)

Cefazolin
vascular access Staph.
epidermidis Cefamandol(15)
6 3
24 3-5
Cepharadine,
Kanamycin Cephalothin (topical antibiotics)
(16,17,18)
Staph.aureus, Staph. epidermidis E. coli

Cephalosporin
(19) ( 5.1)
Cefazolin 1st generation Cephalosporin
Cephalothin half life
Cefazolin
24
(14,15)
4 1
(13,15)
55
ANTIBIOTICS IN VASCULAR SURGERY
5.1
aorta
S.aureus, S. epidermidis
enteric, gram-negative bacilli
Cefazolin
S.aureus, S.epidermidis, enteric,

gram-negative bacilli,anaerobes
Cefoxitin
Staph. epidermidis Cephalosporin Vancomycin

Staph.
aureus Methicillin Cefamandol
Vancomycin (20)

aorta

Cefezolin
1 30
1 1
6 3 24
arterial line, endotracheal tube

5-7

24
PRIMARY VASCULAR INFECTIONS

(primary)

1. mycotic aneurysm
2. syphilitic aortitis
3. spontaneous aortoenteric fistulas

1. primary infection microbial arteritis traumatic aneurysm
2. secondary infection infected aneurysm

(20)
mycotic aneurysm
1. septic emboli cardiac vegetative
endocarditis
2. atherosclerotic aneurysm

bacteremia
3.

4.
osteomyelitis, ,
mycotic aneurysm

56
syphilitic aneurysm, tuberculous aneurysm true
fungal aneurysm

Histoplasma capsulatum, Aspergillus fumigatus, Candida
albicans Penicillium species
spontaneous aorta-enteric fistula graft
enteric fistula AAA

mycotic
aneurysm aorta femoral mesenteric
Staph.aureus, Salmonella, Streptococci,
Pseudomonas E.coli mycotic aneurysm
arteriography
( aorta)
leukocytosis
arteriogram
saccular aneurysm petecheae
CT scan aorta
aneurysm

mycotic aneurysm
extra-anatomical bypass

6 Salmonella
Ampicillin Chloramphenical
mycotic aortic aneurysm
aorta,
(in
situ) 8
aortic stump
12-87
(gangrene)

(21) dry gangrene
demarcation
wet gangrene

Cefoxatime, aminoglycoside
clindamycin (22)
ANTIBIOTICS IN VASCULAR SURGERY
57
1. Kaiser AB. Antimicrobial prophylaxis in surgery. N Eng J Med

1986;315:1129-1138.
2. Szilagyi DE, Smith RF, Elliott JB. Infection in arterial reconstruction
with synthetic grafts. Ann Surg 1972;176:321-333.
3. Burnakis TG. Surgical antimicrobial prophylaxis: Principles and guidelines. Pharmacology 1984;4:248-271.
4. Crause PJE, Foord R. A five year perspective study of 23, 649
surgical wounds. Arch Surg 1973;107:206-210.
5. Antimicrobial prophylaxis in surgery. Med lett Drugs Ther
1989;31:105-111.
6. Kaiser AB, Clayson KR, Mulberin JL, et al. Antibiotic prophylaxis in
vascular surgery. Ann Surg 1976;188:283-289.
7. Hasselgren PO, Ivarsson L, Risberg B. Effects of prophylaxis antibiotics in vascular surgery. Ann Surg 1984;200:86-92.
8. Nichols RL. Surgical wound infection. Am J Med 1991;91:54-61.
9. Nichols RL. Postoperative wound infection. N Engl J Med
1982;307:1701-1706.
10. Windser JA, Hill GL. Weight loss with physiologic impairment: Basic indicator of surgical risk. Ann Surg 1988;207:290-297.
11. Buckel JA, Wilson SE. The prevention and management of prosthetic graft infection. In:Wilson SE, ed. Vascular Surgery. Philadelphia, WB Saunders 1987:889-897.
12. Bandyk DF, Berni GA, Thiele BL. Aortofemoral graft infection due to
Staphylococcus epidermidis. Arch Surg 1984;119:102-108.
13. Worning AM, Fuimodf-Moller N, Ostri P, et al. Antibiotic prophylaxis in vascular reconstructive surgery. J Antimicrob Chemother
1986:17:105-113.
14. Bennion RS, Hiatt JR, Williams RA. A randomized prospective study
of perioperative antimicrobial prophylaxis for vascular surgery. J
Cardiovasc Surg 1985;26:270-274.
15. Fracet G, Brister S, Richard GK, et al. Antibiotic prophylaxis in
vascular surgery: Pharmacokinetic study of commonly used cephalosporins. J Vasc Surg 1986;3:535-539.
16. Lord JW, Ross G, Daliana M. Intraoperative antibiotic wound lavage. Ann Surg 1977;185:634-638.
17. Pitt HA, Postier PG, McGowan WAC, et al. Prophylactic antibiotics
in vascular surgery, topical, systemic or both?. Ann Surg
1980;192:356-364.
18. Matashek KJ, Rosin E. Pharmacokinetics of Cefazolin applied topically to the surgical wound. Arch Surg 1991;126:890.
19. Abramovicz M. Antimicrobial prophylaxis in surgery. Med lett
1987;29:91-94.
20. Wilson SE, Van Wagenen P, Pessaro E. Arterial infection. Curr Prob
Surg 1978;15:6-89.
21. Freier J, Daniel D, Davis C. Fetid foot: Lower extremity infections in
patients with diabetes mellitus. Rev Infect Dis 1979;1:210-217.
22. Freischlag J, Ajalat G, Busutil RW. Treatment of necrotizing soft
tissue infections: The need for a new approach. Am J Surg
1985;149:751-755.
58
6
NONINVASIVE
VASCULAR STUDIES

noninvasive hemodynamic studies
noninvasive tests

noninvasive tests

arteriogram venogram
noninvasive tests
clinical vascular laboratories

arteriogram, peripheral vasscular disease (PVD) 25
noninvasive tests

VASCULAR LABORATORY

por-
table continuous-wave Doppler unit

portable
Doppler unit
vascular lab
1.
2.
3.
4. exercise
5.

1. continuous-wave bidirectional Doppler system
9 mHz 5 mHz
2. plethysmography
3. duplex ultrasound bruit imaging

4. treadmill 1.5 2.5 , 10-25%
grade
5. transcutaneous oximetry cutaneous perfusion
60
DOPPLER ULTRASOUND
Doppler flow detector
blood flow Doppler
effect wave frequency (sound)
(reflector) ( 6.1)
probe frequency probe frequency reflector
( 6.2)
Doppler flow defectors 2
RBC
Direction
6.1 Doppler effect

reflector
reflector
Probe
Skin
6.2 Doppler
Doppler probe
acoustic gel probe
Doppler
arterial signal triphasic
monophasic signals
1. continuous-wave Doppler probe

ultrasound waves
probe
probe
high pitched arterial signal low pitched

venous signal

5-10 mHz
bidirector direction
velocity
2. pulsed-wave Doppler flow detector
ultrasound waves piezoelectric crystal
probe pulsed-wave Doppler
duplex scanner
velocity profile

PLETHYSMOGRAPHY

arterial plethysmography pulse
volume
cardiac cycle venous plethysmography

plethysmography
water displacement, strain gauge impedance air
plethysmography air
plethysmography
pulse volume recorder (PVR) pneumatic cuff
inflate cuff 65
pressure transducer
cardiac cycle

cuff ( 6.3)
wave form air plethysmography
limb perfusion
(
)
61
NONINVASIVE VASCULAR STUDIES
6.3 Pulse volume recordings PVR prolong

plethysmography

plethysmography
1. pulse volume recorder (PVR)

Raines Darling Massachusettes
General Hospital segmental plethysmograph
monitor pulsatility blood flow
PVR air-filled cuff
( 6.4)
air-filled cuffs pulse volume
changes arterial
pulse contours direct intraarterial
pressure Doppler segmental limb
pressure
Doppler unit
2. ocular plethysmography (OPG)

arterial
pulsation
2 Kartchner-McRae OPG methods
delay in volume filling

plethysmography OPG-Gee
sclera intraocular pressure
plethysmography internal carotid artery
60 ()
indirect tests
direct invasive tests duplex scan

routine
3. photoplethysmography (PPG)
6.4 segmental pressure cuffs
, ,
one-cuff two-cuff
direct method cutaneous blood flow

photoelectric sensor
cutaneous circulation arterial pulsation
venous congestion dermal circulation PPG
62
4. impedence plethysmography (IPG)

Wheeler
acute chronic DVT
Ohms law
voltage = current x resistance

DVT venous
outflow peripheral vasoconstriction, ,
pulmonary hypertension
5. phleborheography (PRG)
air-filled cuffs

DVT respiratory waves
waves
95

DUPLEX SCANNING
real-time B-mode ultrasound image pulsed Doppler spectral analysis
flow velocity water soluble acoustic gel
probe
calcified plaques
ultrasound B-mode blood
flow flow probe flow
probe velocity
carotid bifurcation disease
turbulent
flow
, ,
renal arteries
duplex scanning
noninvasive test

TRANSCUTANEOUS OXIMETRY (TCPO2)
local skin oxygen tension arterial capillary perfusion

45o C localized hyperemia
oxygen excess concentration
gradient capillaries
electrochemical
modified Clark platinum oxygen
electrode standardize vosodilation
43o C ratio TcPO2 arterial
PO2 1.
CT scan
computed tomography (CT)

series x-ray beams spiral
CT CT scan
CT scans.
MAGNETIC RESONANCE TECHNIQUES

1. magnetic resonance imaging
nuclear magnetic resonance
. 1940
1980 magnetic resonance imaging
(MRI) hydrogen
nuclei (radiowaves)
noninvasive test.
2. magnetic resonance flowmeter
arterial flow
standard MR imagers
blood flow
plethysmography
3. magnetic resonance angiography (MRA)

63
laminar flow turbulent flow

turbulent flow flow MRA
2
NONINVASIVE TESTS
I. LOWER EXTREMITY ARTERIAL

OCCLUSIVE DISEASE
2
intermittent claudication severe
ischemia (rest pain, nonhealing ulcers, gangrene)
noninvasive tests claudication
bypass
reconstruct revascularization.
1. Intermittent claudication (IC) IC
Doppler survey ankle pedal arterial signals
ankle-brachial pressure indices (ABIs)
segmental pressures plethysmographic
wave forms (PVRs) exercise.
1.1 Doppler survey
doppler probe arterial signal
2-3 components high-pitched sound
blood flow systole
component reversed reversal
flow diastole diastole forword
flow third low-pitched sound ( 6.2)
severe proximal arterial stenosis occlusion Doppler signal low-pitched
monophasic
Doppler signal exercise
monophasic Doppler sound
6.5 ankle systolic pressure blood pres-
sure cuff portable continuous-wave Doppler

unit ankle pressure brachial (arm)
pressure ABI 1, claudication 0.5-0.9, ischemic rest pain
tissue necrosis 0.5
exercise
Doppler signals
femoral, popliteal, posterior tibial
dorsalis pedis.
1.2 segmental leg pressures
pressure cuffs
,
( 6.4) Doppler probe plethysmograph systolic pressure cuff
( 6.5) segmental leg
pressures
. systolic ankle pressure
systolic arm pressure anklebrachial pressure ratio 1.0
0.5-0.8
0.5
64
.
pressure gradient 20

. segmental leg pressures

1.
pressure cuffs

2. collaterals develop
pressure gradient
20
3. superficial femoral artery thigh
arm ratio iliac
femoral pulse

Doppler blood flow velocity
segmental leg pressures

exercise test, PVRs
Doppler wave form analysis.
1.3 Pulse volume recordings
segmental leg pressure pressure cuffs
PVR tracing sharp upstroke,
pulse peak
tracing prolong (
6.3) IC popliteal
artery entrapment medial head of
gastrocnemius PVR tracing
exercise gastrocnemius
popliteal artery PVR tracing
1.4 Exercise testing exercise
systolic ankle pressure

exercise ankle pressure
2 1) flow
turbulent flow 2) shunt
collateral beds
exercise re-
active hyperemia test high thigh

cuff 50 arm pressure 5
systolic ankle pressure
exercise pressure
treadmill 2
10 5
test claudication cardiorespiratory
preserve
ankle pressures PVRs
exercise claudication
time of onset, location
serial treadmill examination
progression
anastomotic stenosis exercise test vascular neurogenic claudication
peripheral vascular disease
continual EKG monitoring treadmill exercise
1.
2. angina pectoris nitrates
3. COPD
4. cardiac arrhytmia arterial
PVR
5. antiarrhytmic drugs

6.
7. permanent pacemaker
8. stroke TIAs
monitor EKG exercise
treadmill exercise
1. angina pectoris exercise
2. 6
3. cardiac arrhytmia
monitor EKG
treadmill exercise test
1.
2.
3.
4. severe claudication
exercise monitor EKG
1. 120
2. ventricular arrhythmia
3. ST segment depression 2
1.5 Penile/brachial pressure index (PBI) aortoiliac
occlusive disease (AIOD) vasculogenic
impotence
vasculogenic nonvasculogenic impotence
,
AIOD
PBI 0.6
vasculogenic impotence border line 0.6-0.7 vasculogenic
impotence
1. rest PBI 0.7
standard exercise treadmill testing (SETT)
2. rest PBI 0.7 SETT
0.1 PBI 0.7
II. SEVERE ISCHEMIA

rest pain, nonhealing foot lesions
gangrene treadmill exercise
PVRs
Doppler system
1. rest pain neuropathic
ischemic rest pain
65
peripheral
neuropathy systolic ankle pressure
55 ischemic rest pain systolic ankle pressure 35 (
35-50 ) ankle PVR minimal deflection ( 5 ) systolic ankle
pressure

pressure cuffs
toe pressure 30
TcPO2
55
30
0-10

2.

, venous disease, diabetic neuropathy, , collagen diseases
ankle pressure 55
80
PVR tracing
minimal deflection ( 5 )
TcPO2
20-30
3. stump healing

vascular tests PVR
ankle pressure PVR
transmetatarsal
TcPO2 40 stump
III.
bypass
claudication graft
patency duplex scanning real-
66
time-B-mode imaging
IV. EXTRACRANIAL CEREBROVASCULAR

DISEASE
noninvasive tests cerebrovascular disease
cerebral angiography
angiography
1-2
hemodynamic noninvasive test angiography
1. noninvasive cerebrovascular tests

noninvasive tests
cerebrovascular disease

1.1 asymptomatic cervical bruit
1.2 dizziness
1.3 carotid endarterectomy restenosis
1.4 carotid stenosis
( 50)
1.5
1.6
carotid endarterectomy thrombosis
1.7
TIAs cerebral angiography

duplex ultrasound

intrathoracic origins brachiocephalic arteries , aneurysm
, ulcerative lesions intravenous-digital
subtraction arteriograms (IV-DSAs) MRA
noninvasive tests

hemodynamics
duplex sonography
vertebral arteries posterior cerebral symptoms
direction of flow
subclavian steal syndrome posterior
circulation insufficiency
Transcranial Doppler (TCD) hemodynamics
2. Noninvasive carotid artery studies

2 indirect direct methods
indirect
supraorbital Doppler analysis ocular plethysmography
carotid stenosis
ulcerative lesions
tight
stenosis direct methods
extracranial carotid arteries (ultrasonic scans)
(continuous pulsed Doppler spectral analysis)
test duplex
scan OPG-Gee
2.1 Indirect methods Transcranial

Doppler pneumoplethysmography (OPG-Gee)
2.1.1 Ocular pneumoplethysmography (OPG-Gee)
opthalmic artery
hemodynamic
( 50)
85-95 OPG-Gee

ulcerative plaques severe stenosis occlusion internal carotid
artery
OPG-Gee plastic cup
lateral sclera monitor
1.
2. acute chronic conjunctivitis
3. detached retina
4. 6
5. glaucoma
6.
7.
8.
OPG-Gee
1. ophthalmic artery pressures
2 5
2. eye pressures
ratio brachial artery pressure
67
0.6 (
)
3. 1-4 ratio
opthalmic brachial pressure 0.66
OPG
carotid artery
intrathoracic origin, carotid bifurcation,
carotid siphon ophthalmic artery
2.1.2 Transcranial Doppler noninvasive method

TCD pulses ultrasound 2-MHz
probe probes

internal carotid artery siphon, anterior cerebral
artery, middle posterior cerebral artery,
opthalmic artery TCD
1. intracranial collateral patterns hemodynamics

2.
3. vasospasm subarachnoid hemorrhage
4. monitor hemodynamic effects
AVM
5.
6. monitor
6.6 Internal carotid artery
Doppler spectrum patterns

,
68
2.2 Direct methods carotid phonoangiography, continuous-wave Doppler velocity wave form
analysis, bruit anslysis, Doppler scans duplex scanning duplex scan direct method

2.2.1 Duplex scanning Bmode ultrasound image system pulsed
Doppler detector
plaque
velocity patterns flow
signals
( 6.6)
95-97
V. DEEP VENOUS THROMBOSIS (DVT)

DVT
venogram invasive
phlebitis 50 DVT
venogram
DVT invasive tests
venography
noninvasive venous studies impedance

plethysmography, Doppler venous auscultation, I125 fibrinogen scanning, radionuclide phlebography Doppler
ultrasonic imaging
1. Venous plethysmography
DVT
plethysmography impedance, mercury strain
guage volume displacement
80
plethysmography venous obstruction
DVT
venous resistance outflow
plethysmography
venous plethysmograph
pressure cuff 45-50
45 cuff tracing
calf volume
inflate cuff venous capacitance (VC) ( 6.7)
deflate cuff
maximum venous outflow (MVO) plot
VC MVO deep vein
6.7 A. high-frequency low-in tensity 2 outer electrodes

voltage 2 inner electrodes thigh cuff
B. IPG tracing () (DVT) ()
69

venous pooling external rotation

popliteal vein.
plethysmography

acute
chronic occlusion
,
, , ,
2. Duplex venous ultrasonography

noninvasive test
thrombi
vena cava, jugular, portal veins
common femoral popliteal veins
intraluminal soft tissue mass
valsalva maneuver
thrombus femoral popliteal veins
common femoral vein
collaterals valsalva maneuver competent iliofemoral valves
femoral flow
venous duplex DVT
95-98

noninvasive tests DVT
venography

venography
noninvasive tests iliofemoral venous thrombosis
DVT anticoagulants
venography
20

angiography
venography

invasive methods

, ,

angioplasty thrombolytic therapy
20
noninvasive methods

invasive methods noninvasive
tests duplex scanning
hemodynamics
velocity of flow
angiography
venography

invasive tests noninvasive tests
invasive tests
magnetic resonance angiography
(MRA), Spiral CT scanning, plethysmography, duplex scanning
invasive disease

70
1. Baker JD. The vascular laboratory. In: Moore WS, ed. Vascular
Surgery: A Comprehensive Review. 4th ed. Philadelphia: WB
Saunders, 1991;168-85.
2. Fronek A. Noninvasive Diagnostics in Vascular Disease. New
York: McGraw-Hill, 1989.
3. Kempzinski KE, Yao JST (eds). Practical Noninvasive Vascular Diagnosis, 2nd ed. Chicago: Year Book, 1987.
4. Zwiebel WJ (ed.). Introduction to Vascular Ultrasonography. 3rd
ed. Philadelphia: WB Saunders, 1992.
5. Strandness DE. Duplex Scanning in Vascular Disorders. New York:

Raven Press, 1990.
6. Sumner DS. Noninvasive assessment of peripheral arterial occlusive disease. In:Rutherford RB. ed. 3rd ed. Philadelphia: WB Saunders,
1989;61-111.
7. Sumner DS. Objective diagnostic techniques: Role of vascular lab.
In: Rutherford RB, ed. 3rd ed. Philadelphia: WB Saunders, 1989;4160.

arteriography, venography, ultrasonography (US), computed
tomography (CT), digital subtraction angiography (DSA),
magnetic resonance imaging (MRI), positron emission
tomography (PET) angioscopy
(radiological intervention) (percutaneous angioplasty PTA) embolization
(thrombolytic therapy)
,
,

I. ARTERIOGRAPHY

atherosclerosis noninvasive test
arteriography invasive diagnostic procedures

noninvasive test
arteriography(1) arteriography
(PTA), atherectomy
arteriography
arteriography

arteriography check list
( 7.1)
(contrast media)
methylglucamine methylglucamine triiodo2,4,6-benzoic acid osmolarity

proteinuria,

72
1
2-5
anaphylactic shock, ,
wheeze
arteriogram

steriod diphenylhydramine prednisolone 50 6 arteriogram diphenylhydramine 1
arteriogram(2)
Iopamidol
Iohexol nonionic monomer osmolarity

arteriography

Seldinger technique

femoral
carotid, , aorta
aortoiliac occlusive disease
(AIOD) femoral
brachial axillary
aorta lumbar
brachial

highly selective catheterization

embolization
arteriogram
6
mental status
()

12-24

4-6
7.1 Preangiography Check list

1. arteriography
2. BUN, Cr
3.
4. 3-6
5.
6.

fibrinolytic (fibrinogram fibrin degradation products)

Povidone iodine Chlorhexidine
73
(2)
1. (allergic reaction)
5 1:16,000
1:117,000
2. (nephrotoxicity)
osmolarity

proteinuria

3.

cerobrovascular accident (CVA) pheochromocytoma
hypertensive crisis pulmonary edema
4. blood brain
barrier
cortical blindness
(mechanical complications)
thrombosis, pseudoaneurysm arteriovenous fistula 0.5-1%
6
brachial thrombosis axillary

Staph. aureus Streptococci

II. Contrast Venography

Duplex ultrasound

bypass
subclavian venography arteriography
3-5
venography
thrombophlebitis
III. Ultrasound (US) Computed

Tomography (CT)
noninvasive method
aneurysm
(3) arteriography ulcerated
plaque duplex scan
Magnetic Resonance Imaging (MRI)
hemangioma,
arteriovenous malformations (AVM),
aortic arch US CT scan

CT scan

1. Abdominal Aortic Aneurysm
(AAA) US intraluminal thrombus

74
AAA
renal artery iliac arteries
US
CT scan
aorta AAA
renal artery
2. peripheral aneurysms
femoral popliteal
3. deep vein thrombosis iliofemoral veins
4.
false aneurysm
AAA
Iliac
indium - labeled
leukouyte scans.
IV. Digital Subtraction Angiography

(DSA)(4)
arteriography
antecubital vein superior venacava (SVC)
fluoroscope
2-3
arteriogram

conventional arteriography

(
) conventional
arteriography intra arterial digital subtraction arteriography (1D-DSA)

V. Magnetic Resonance Imaging

hydrogen ion (proton)

scan MRI
aortic
dissection intimal flap aorta
mural thrombus lumen
(5)
noninvasive test blood
flow velocity
(transverse, sagittal coronal planes)

VI. Duplex Ultrasonography

aortic arch vertebral

noninvasive test
segment pressure measurement
Color Doppler imaging
claudication follow up
reconstruction arteriography
VII. Positron Emission Tomography

(PET)
CT MRI
3 MR spectroscopy
PET
labeled positron-emitting isotope

PET regional blood
75
flow, oxygen consumption substrate (glucose) utilization

PET metabolic response
revascularization

arteriography,
US CT scan

noninvasive test
Doppler US MRI
ENDOVASCULAR TREATMENT TECHNIQUES

endovascular treatment

percutaneous transluminal angioplasty (PTA),
Thrombolytic therapy, Atherectomy, Angioscopy Intraluminal vascular stent
(1)
I. Angioscopy
1. Dyer R (ed). Handbook of Vascular and Interventional Radiology.

Churchill Livingstone, 1993.
2. Bush WH, Swanson DP. Acute ractions to intravascular contrast
media: Types, risk factors, recognition, and specific treatment. AJR
1991;157: 1153.
3. Tumch SS, Seltzer SE, Wang A. Computed tomography in Vascular
Disorder. In: Loscalzo J, Greager MA, Dzau VJ (eds) Vascular Medicine. Boston: Little, Brown, 1992;81-102.
4. Bettmann MA. Principles of Angiography. In:Loscalzo J, Creager
MA, Dzau VJ (eds.), Vascular Medicine. Boston: Little, Brown,
1992;155-173.
5. Glazer HS. The thoracic aorta studied by MR Imaging. Radiology
1985;157:149.

(2) angioscope
0.5-3.3 fiberoptic

3 thrombectomy
thrombus arteriogram
angioscope
arteriography

intima
spasm thrombosis
angioplasty stent

II. Percutaneous Transluminal

Angioplasty
Dotter 1964(3)

atherosclerotic plaque

media elastin collagen fibrins
76
PTA
aorta, renal
mesenteric arteries, subclavian coronary arteries
hemodialysis fistula

PTA
5 (short segment)
iliac superficial femoral(4)
(stent)
(5) ( 7.1)

95 5-year patency 75-90(6)
30
6 (7)
PTA
PTA (6)
1. 5
2. blood outflow
3. claudication limb theratening

condition
4.
femoral, popliteal terminal aorta 85-95

5-year patency 75-90(8) Renovascular
hypertension (RVH) fibromuscular
dysplasia 87-100
57 27(9)
5-10 0-2
thrombosis
thrombus

81-325 24-48 PTA
2-3 PTA 2,5005,000 Coumadin 1-3
PTA
III. Atherectomy Devices

Simpson atherectomy cath, The
Kensey atherectomy device, The Auth Rotablator
The transluminal extraction catheter
7.1 . percutaneous transluminal angioplasty (PTA)

. stent
77
V. Thrombolytic Therapy
7.2 plaque
atherectomy catheter
(10) atheromatous debris atherosclerotic arteries ( 7.2)

intima intima hyperplasia
PTA
IV. Laser Angioplasty

10
atherosclerotic lesions(11,12)
fiberoptic

plaque vaporization laser vaporization

fiberoptic
argon eximer plaque
calcified plaque
plaque

( 7.3)
(13,14)
streptokinase (SK),
Urokinase (UK), tissue plasminogen activator (TPA)
SK UK exogenous plasminogen activator
plasminogen plasmin
fibrin clots
SK streptococci

antigenic
UK
embryonic kidney cell 14
nonantigenic low pyrogenicity

recombinant DNA recombinant UK

tissue culture UK
TPA recombinant DNA

plasminogen
fibrin clot plasminogen
7.3 laser beam
78

UK 250,000 2-4
arteriography
UK
arteriography
systemic fibrinolysis
VI. Intraluminal Vascular Prostheses

endovascular therapy vascular bypass graft
(15,16)
bypass

Intraluminal prostheses
3
( 7.4)

endovascular
therapy

7.4 endovascular therapy vascular

bypass graft
AAA
79
1. Ahn SS, Eton D, Moore WS. Endovascular surgery for peripheral

arterial occlusive disease: A critical review. Ann Surg 1992;216: 316.
2. White GH, White GA (eds.). Angioscopy: Vascular and Coronary
Applications, Mosby Year Book, 1989.
3. Dotter CT, Judkins MP. Transluminal treatment of atherosclerotic
obstruction: Description of a new technique and a preliminary report of its application. Circulation 1964;30:654.
4. Van Andel GJ, van Erp WFM, Krepel VM, et al. Percutaneous
transluminal dilatation of the iliac artery: Long term results. Radiology 1985;156:321.
5. Martin ML, Veith FJ, Panetta TF, et al. Transfemoral stent graft
treatment of occlusive arterial disease for limb salvage: A preliminary report. Circulation 1993;88:1.
6. Mahler F, Gallino A, Probst P, et al. Factors influencing early and
late follow-up result after percutaneous transluminal angioplasty of
the lower limb arteries. In:Dotter CT, Grunring A, Schoop W, et al,
eds. Percutaneous transluminal Angioplasty. Berlin:Springer,
1983:199.
7. King SB III, Schlumpf M. Ten-year completed follow-up of percutaneous transluminal coronary angioplasty. The early Zurich experience. J Am Coll Cardiol 1993;22:353.
8. Tegtmeyer CJ, Kellum CD, Kron IL, et al. Percutaneous transluminal

angioplasty in the region of the aortic bifurcation. Radiology
1985;157:661.
9. Schwarten DE. Transluminal angioplasty of renal artery stenosis: 70
experiences. Am J Roentgenol 1980;135:969.
10. Ahn SS, Eton D, Yeatman LR, et al. Intraoperative peripheral rotary
atherectomy: Early and late clinical results. Ann Vasc Surg
1992;6:272.
11. White RA. White GH. Laser angioplasty: Development, current status and future perspectives. Sem Vasc Surg 1989;2:123.
12. Sanborn TA. Peripheral laser assisted balloon angioplasty: Initial
multicenter trial in 219 peripheral arteries. Arch Surg 1989;168:121.
13. McNamara TO, Bombergen RA, Merchant RF. Intra-arterial urokinase as the initial therapy of acutely ischemic lower limbs. Circulation 1991;83:1106.
14. Montarjame A. Thrombolytic therapy in acute arterial occlusion
and graft thrombosis. Semin Vasc Surg 1989;2:155.
15. Parodi J. Endovascular repair of abdominal aortic aneurysms. In:
Advances in Vascular Surgery. Whittemore ET, et al(eds.) MosbyYear Book. 1993:85.
16. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft
implantation for abdominal aortic aneurysms. Ann Vasc Surg
1992;5:491.
80
( 8.1)
..
1906 Carrel Guthrie
(1) (venous
autograph)
(xenograft)

..
1952 Voorhees Vinyon-N-cloth
aorta(2)

4

( 8.2)
1.
1.1 (arterial autografts)
(3,4)
coronary artery internal mammary

artery saphenous vein graft renal
artery reconstruction internal liac artery
aneurysmal dilatation
saphenous vein graft

aorta renal artery
1.2 (venous autografts)

greater lesser saphenous vein, cephalic vein, brachial vein, superficial femoral
vein, internal, internal jugular vein
8.1
1.
2.
3.
4.
5.

6.
7.
82
8.2
(textile)
Woven Dacron
Knitted Dacron
Velour
Biological
Nontextile
Teflon (ePTFE)
Polyurethrane
Bioabsorbable
Allograft
End-to-end
Arterial homografts straight graft
Venous allografts Sequential grafts
Umbilical vein
Xenografts
Bovine carotid
Canine carotid
Fibrocollagenous tubes
Autogenous
Heterogenous

greater saphenous vein

(valve)
(reversed saphenous vein graft)
in situ saphenous
vein bypass greater saphenous vein
valvulotome venous valve saphenous vein

saphenouse vein

(5)
autogenous reversed saphenous vein graft
femoral politeal
1 80-90
5 55-86 10 38-46

tibial
10

(6,7)
in situ saphenous vein

bypass reversed saphenous vein bypass(8,9,10)
1.3 Human umbilical vein grafts (HUVG)

50 6-7
1% glutaraldehyde Dacron

1.4 (Xenografts)

nonantigenic collagen tube diadehyde
starch
1.5 Fibrocollagenous tubes

30
hypercoagulable (7) 60
progressive atherosclerosis

fibrosis
atherosclerosis (11,12) fibrointimal
hyperplasia 10
15-30 coronary artery bypass(13) fibrointimal hyperplasia
shearing force (14,15)

growth inhibiting factor
(16,17)
83
2.
Dacron
polytetra fluoroethylene
2.1 Dacron grafts
(multifilaments) Woven

Knitted graft
preclotted
double velour Dacron graft
velour surface
preclotted
(18) preclotted
impregnated autoclave Dacron graft
(19)
2.2 Polytetrafluoroethylene (PTFE) grafts
inert polymer solid nodes
PTFE interconnecting fobrils
electronegative surface charge
hydrophobic
(20)
3.
(composite grafts)

bypass
A
8.1 composite graft
A. end-to-end anastomosis
B. composite sequential bypass graft

(21,22) ( 8.1)

Dacron graft
aortofemoral bypass
5-10 91 66
axillofemoral bypass 5
75 femorofemoral bypass 5
75-80(23)
PTFE

PTFE graft Dacron graft

(24,25)
coronary artery bypass
graft (CABG)
vascular
access
84
(PROSTHETIC GRAFT HEALING)

intima

fibrin (26)

(27)

neointimal hyperplasia
false aneurysm
Dacron PTFE

(28,29)
false aneurysm

compliance mismatch(30,31)

1-2
(32)
(33)
(34)
thrombus

(35)
(endothelial seeding grafts)
(biodegradable prostheses)

(36,37)
aneurysm
-
(impregnated graft)
(36)
(37) S. epidermidis

cellulitis
septic
emboli (38-46)

(leukocytosis) erythrocyte sedimentation rate (ESR)
isotope tagged WBC

nuclear medicine WBC
(47)
CT scan MRI
diverticular disease
85

7-10
revescularization(48,49)

extra-anatomical bypass abdominal aorta
axillo-bifemoral bypass
in situ bypass
(50)
1. Carrel A, Guthrie CG. Uniterminal and biterminal venous transplantations. Surg Gynecol Obstet 1906;2:266-271.
2. Blakemore AH, Voorhees AB Jr. Use of tubes constructed from
vinyon N cloth in bridging arterial defects: Experimental and
clinical. Ann Surg 1954; 140:325-331.
3. Edwards WS. Arterial grafts, Past, present, and future. Arch Surg
1978; 133:1225-1233.
4. Stoney RJ, Wylie EJ. Arterial autografts. Surgery 1970;67:18-24.
5. Leather RP, Shah DM, Buchbinder D, et al. Further experience
with the saphenous vein used in situ for arterial bypass. Am J
Surg 1981;142:506-512.
6. Taylor LM, Edwards JM, Porter JM. Present status of reversed vein
bypass grafting:Five-year results of a modern series. J Vasc Surg
1990;11:193-201.
7. Sonnenfeld T, Cronestrard R. Factors determining outcome of reversed saphenous vein femoropoliteal bypass grafts. Br J Surg
1980;67:642-648.
8. Batson RC, Sottiurai VS. Nonreversed and in situ vein grafts. Ann
Surg 1985;201:771-779.
9. Buchbinder D, Singh JK, Karmody AM et al. Comparison of patency rate and structural change of in situ and reversed vein arterial bypass. J Surg Res 1981;30:213-219.
10. Bergamini TM, Towne JB, Bandyk DF, et al. Experience with in
situ saphenous vein bypasses during 1981 to 1989:Determinant
factors of long-term Patency. J Vas Surg 1991;13:137-141.
11. Fuchs JCA, Mitchener JS III, Hagen P. Postoperative change in
autologous vein grafts. Ann Surg 1978;1:188-193.
12. Reifsynyder T, Towne JB, Seabrook GR, et al. Biologic characteristics of long-term autogenous vein grafts: A dynamic evaluation. J
Vasc Surg 1993;17:207-212.
13. Atkinson JB, Forman MB, Vaughn WK, et al. Morphologic changes
in long-term saphenous vein bypass graft. Chest 1985;88:341-348.
14. Bush HL, McCabo ME, Nabseth DC. Functional injury of vein graft
endothelium. Arch Surg 1984;119:770-776.
15. Abbott WM, Wieland S, Austin WG. Structural changes during
preparation of autogenous venous grafts. Surgery 1972;76:10311307.
16. Bonchek LI. Prevention of endothelial damage during preparation
of saphenous veins for bypass grafting. J Thorac Cardiovasc Surg
1980;79:911-916.
17. LoGerfo FW, Quist WC, Crawshaw HM, Haudenschild C. An improved technique for preservation of endothelium morphology in
vein grafts. Surgery 1981;90:1015-1019.
86
18. Goldman M, McCollum CN, Hawker RJ, et al. Dacron arterial
grafts: The influence of porosity, velour, and maturity on
thrombogenicity. Surgery 1982;92:947-954.
19. Quinones-Baldrich WJ, Moore WS, et al. Development of a leakproof Knitted Dacron vascular prostheses. J Vasc Surg 1986;3:895902.
20. Kempczinski RF. Physical characteristics of implanted
polytetrafluoroethylene grafts: A priliminary report. Arch Surg
1979;114:917-922.
21. Edwards WS, Gerety E, Larkin J, et al. Multiple sequential femoraltibial grafting for severe inchemia. Surgery 1976;80:722-731.
22. Flinn WR, Ricco JB, Yao JST, et al. Composite sequential grafts in
severe ischemia: A comparative study. J Vasc Surg 1984;1:449454.
23. Crawford ES, Bomberger RA, Glaeser DH, et al. Aortoiliac occlusive disease: Factors influencing survival and function following
reconstructive operation over twenty-five year period. Surgery
1981;90:1055-1063.
24. Michaels JA. Choice of material for above-knee femoropopliteal
bypass graft. Br J Surg 1989;76:7-13.
25. Tilanus HW, Obertop H, Urk HV. Saphenous vein or PTFE for
femoropopliteal bypass. A prospective randomized trial. Ann Surg
1985;202:780-788.
26. Sauvage LR, Berger K, Wood SJ, et al. Interspecies healing of
porous arterial prostheses: Observations, 1960-1974. Arch Surg
1974;109:698.
27. Graham LM, Burkel WE, Ford JW, et al. Immediate seeding of
enzymatically derived endothelium in Dacron vascular grafts. Arch
Surg 1980;115:1289.
28. Chesebro JH, Clements IP, Furter V, et al. A platelet inhibitor drug
trial in coronary artery bypass operations. N Engl J Med 1982;307:73.
29. Goldman MD, Simpson D, Hawker RJ, et al. Aspirin and dipyridamole reduce platelet deposition on prosthetic femoropopliteal
grafts in man. Ann Surg 1983;198(6):713.
30. Szilagyi DE, Smith RF, Elliott JP, et al. Anastomic aneurysms after
vascular reconstruction: Problems of incidence, etiology and treatment. Surgery 1975;78:800.
31. Dennis JW, Littooy FN, Greisler HP, et al. Anastomotic
pseudoaneurysms. A continuing late complication of vascular reconstructive procedures. Arch Surg 1986;121:314.
32. Bandyk DF. Vascular graft infections: Epidemiology, microbiology,
pathogenesis and prevention. In: Bernhard VM, Towne JB (eds).
Complications in Vascular Surgery. St Louis, Quanlity Medical
Pulbishing. 1991;223-234.
33. Taylor SM, Mills JL, Fujitani RM, et al. The influence of groin
sepsis on extra-anatomical bypass patency in patients with prosthetic graft infection. Ann Vasc Surg 1992;6:80.
34. Sauvage LR, Berger K, Mansfield PB, et al. Future directions in the
development of arterial prostheses for small and medium caliber
arteries. Surg Clin North Am 1974;54:213.
35. Herring MB, Baughman S, Glover JL, et al. Endothelial seeding of
Dacron and poly tetrafluoroethylene grafts: The cellular events of
healing. Surgery 1984;96:745.
36. Shue WB, Worosilo SC, Donetz AP, et al. Prevention of vascular
prosthetic infection with an antibiotic-bonded Dacron graft. J Vasc
Surg 1988;8:600.
37. Esquivel CO, Bjorck C-G, Bergentz S-E, et al. Reduced thrombogenic characteristics of expanded polytetrafluroethylene and polyurethane arterial grafts after heparin bonding. Surgery 1984;95:102.
38. Bandyk DF. Vascular graft infection: epidemiology, bacteriology,
and pathogenesis. In:Bernhard VM, Towne JB. (eds) Complications
in Vascular Surgery. New York: Grune & Stration, 1985;471-494.
39. Bunt TJ. Synthetic vascular graft infection; I. Graft infection. Surgery 1983;93:733-741.
40. Seabrook GR, Schmitt DD, Bandyk DF, et al. Anastonotic femoral
pseudoaneurysm: An investigation of occult infection as an etiologic factor. J Vas Surg 1990;11:629-636.
41. Bandyk DF, Berni GA, Thiele BL, et al. Aortofemoral graft infection
to Staphylococcus epidermidis. Arch Surg 1984;119:102.
42. Ernst CB, Campbell HC, Daugherty ME, et al Incidence and significance in intraoperative bacterial culture during abdominal abdominal aortic aneurysmectomy. Ann Surg 1977;185:625-633.
43. Leny MF, Schmitt DD, Edminton CE, et al. Sequential analysis of
Staphylococcal colonization of body surfaces of patients undergoing vascular surgery. J Clin Microbiol 1990;28:664-671.
44. MacBeth GA, Rubin JR, McIntyre KE, et al. The relevence of
arterial wall icrobiology to the treatment of prosthetic graft infections: Graft infection versus arterial infection. J Vasc Surg 1984;1:750785.
45. Rubin JR, Malone JM, Goldstone J. The role of the lymphatic
system in acute arterial prosthetic graft infection. J Vasc Surg
1985;2:92-98.
46. Schmitt DD, Bandyk DF, Pequet AJ, et al. Bacterial adherance to
vascular prostheses: A determinant of graft infectivity. J Vasc Surg
1986;3:732-739.
47. Lawrence PF, Dries DJ, Alazraki N, Albo D. Indium 111-labeled
leukocyte scanning for detection of prosthetic graft infection. J
Vasc Surg 1985;2:165.
48. Lorentzen JE, Nielsen, OM, Arendrup H, et al. Vascular graft infection; An analysis of sixty-two graft infections in 2411 consecutively
implanted synthetic vascular grafts. Surgery 1985;98:81.
49. Reilly LM, Ehrenfeld WK, Stoney RJ. Delayed aortic prosthetic
reconstruction after removal of an infected graft. Am J Surg
1984;148:234.
50. Turnipseed WD, Berkoff HA, Detmer DE, et al. Arterial graft infections: delayed versus immediate vascular reconstruction. Arch Surg
1983;118:410.

atherosclerosis

15-25
40-60(1) 40

16 3
left main coronary artery(2)

angina pectoris dyspnea on
exertion ?
?

(3,4,5)
1. 6
2.
3. A wave
4. angina
5.
6. ventricular arrhytmia
7. 70
8.
9. cardiovascular accident (CVA)
1. (EKG)
12 leads Awave infarction
35
exercise
test
(6,7)
85 ST seg-
88
ment depression
exercise test

B-blocker exercise test

2. echocardiography and radionuclide

ventriculography
ejection fraction (EF)
EF
EF
35(8,9) EF coronary
heart disease
screen test invasive monitoring

3. electrographic monitoring

(10) 20
25 41
(11)
4. dipyridamole-Thallium Scintigraphy (DTS)

(12) dipyridamole

thallium cardiac perfusion
dipyridamole 4
thallium 201 isotope scan scan
scan
uptake thallium scan uptake
uptake

cardiac catheterization
dipyridamole aminophyline
DTS
xanthine derivatives aminophyline caffeine.
5. Dobutamine Stress Echocardiography (DSE)
(13) dobutamine B1 antogonist inotropic chronotropic

dobutamine
monitor 2-dimensional
echocardiography
monitor 2-dimensional echocardiography

atropine antagonist
bronchospasm
dobutamine B-blocker
6. Cardiac catheterization

screening test unstable angina coronary artery bypass graft (CABG)

emphysema bronchitis
clubbing fingers
screeing test(14)
89
blood gas pulmonary

function test (PFT) oxygenation PaO2, alveolar ventilation PaCO2 Forced Expiratory
Volume (FEV1)
1 Total volume
normal ventilatory cycle
Functional Residual Capacity (FRC)
( 9.1)
Flow rates

obstructive
airway disease(14) percentage of expected volume mid expiratory flow rate (FEF25%-75%)
(spirogram) FEF25%-75%
80 150200
Maximal voluntary ventilation
1 150-200

lung compliance dead space tidal volume

9.1

Forced expiratory
volume, 1 second
(FEV1)
Maximal mid expiratory
Flow (FEF25%-75%)
Maximal voluntary
Ventilation
PaO2 room air
PaCO2 room air
>80% predicted
<40-50%
150-200 /
>80% predicted
150-500 /
>80% predicted
85+5 mHg
40+5 mHg
<35-50%
<35-50%
<50-55 mHg
>45-55 mHg
obstructive disease VC
FEV1 FEF25%-70% restrictive disease VC expiratory flow rates
COPD, asthma chronic bronchitis PFT

12

arteriography

NSAID Coumadin screeing test
prothrombin time (PT), partial
thromboplastintime (PTT), platelet counts bleeding
time clotting factors
venous thrombosis multiple graft
failure hypercoagulable work up (15)
graft failure

protein C, protein S,
anticardiolipin, antithrombin III (A-III) lupus
anticoagulant protein C vitamin K dependent glycoprotein factor Va VIIIa
protein S cofactor protein C 50
protein 70 protein S

A-III thrombin actived clotting factors factor X<-->
A-III
A-III DVT pulmonary
embolism
A-III
( 60 ) A-III
90
A-III
lupus anticoagulant anticardiolipin antibodies antiphospholipid antibody syndromes
lupus anticoagulant acquired IgG IgM antibodies Russel viper venom time
anticardiolipin IgM antibodies
enzyme-linked immunosorbent assay (ELISA) cardiolipin antigen prolonged activated PTT antibodies
phospholipid dependent assay

Coumadin
1. Hertzer NR. Basic data concerning associated coronary artery disease in peripheral vascular patients. Ann Vasc Surg 1987;1:616.
2. Ouyang P. Frequency and significance of early postoperative silent
myocardial ischemia in patients having peripheral vascular surgery.
Am J Cardiol 1989;64:113.
3. Wong T, Detsky AS. Preoperative cardiac risk assessment for patients having peripheral vascular surgery. Ann Intern Med
1992;116:743.
4. Coldman L, Cardiac risks and complications of noncardiac surgery.
Ann Intern Med 1983;98:504.
5. Cooperman M. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery 1978;84:505.
6. McCabe CJ. The value of electrocardiogram monitoring during
treadmill testing for peripheral vascular disease. Surgery 1982;83:183.
7. McPhail NV. The use of preoperative exercise testing to predict
cardiac complications after arterial reconstruction. J Vasc Surg
1988;7:60-68.
8. Kazmers A, Cerqueira MD, Zierler RE. The role of preoperative
radionuclide ejection fraction in direct abdominal aortic aneurysm
repair. J Vasc Surg 1988;8:128.
9. Mosley JG, Clarke JMF, Marston A. Assessment of myocardial
function before aortic surgery by radionuclide angiocardio graphy.
Br J Surg 1985;72:886.
10. Gewertz BL. Transesophageal echocardio-graphic monitoring of
myocardial ischemia during vascular surgery. J Vasc Surg 1987;5:607.
11. Goldman L. Cardiac risks and complications of noncardiac surgery.
Ann Intern Med 1983;98:504.
12. Leppo JA. Dipyridamole-thallium imaging:The lazy mans stress
test. J Nucl Med 1989;30:281.
13. McPhai NV. Comparison of left ventricular function and myocardial perfusion for evaluation perioperative cardiac risk of abdominal
aortic surgery. Can J Surg 1990;33:224.
14. Diener CF, Burrows B. Further observation on the course and
prognosis of chronic obstructive lung disease. Am Rev Respir Dis
1975;111:719-724.
15. Samlaska CP, James WD. Superficial thrombophlebitis. I. Primary
hypercoagulable states. J Am Acad Dematol 1990;22:975-989.
16. Donaldson MC, Weinberg DS, Belkin M, et al. Screening for hypercoagulable tates in vascular surgical practice: A preliminary study.
J Vasc Surg 1990;11:825-831.
92
10 Cerebrovascular disease
11
12
13
14
15
16
17
18
19
20
21
22
Abdominal Aortic Aneurysm (AAA)

Aortoiliac Occlusive Disease (AIOD)
Intermittent Claudication (IC)
Renovascular Disease
Femoro-Popliteal-Tibioperoneal Occlusive Disease
Buergers Disease (Thromboangiitis Obliterans)
Takayasus Arteritis
Acute Arterial Occlusion
Infected Aneurysm
The Diabetic Foot
10
CEREBROVASCULAR
DISEASE

carotid, aortic arch branches
verterbral arteries
, ulcerated arterial lesions, aneurysm (1)

high grade (>70%
stenosis) (2)

extracranial carotid vertebral arterial disease
, , ,
,

1. SYMPTOMATIC CAROTID ARTERY DISEASE

1.1 Transient Cerebral Ischemia
Transient Cerebral Ischemia transient
monocular blindness (TMB) amaurosis fugax

lateralizing trasient ischemic attack
(TIA) TMB

atheroemboli carotid
bifurcation TIA
speech disturbance
24
neurologic deficit

TMB TIA
cardiovascular status
atheroemboli
mural thrombus myocardial infarction,
vegetation atherosclerotic debris valvular heart
disease, embolization carotid atheroma
carotid occlusive disease
94
TIA stroke 24-29
5 TIA
70 stroke 40 5 (4)
carotid arteriography
(5)
(3)
1.2 Stroke
complete stroke focal neurologic deficit

24
Stroke Severity Scores disabling
stroke carotid endarterectomy(6,4)
acute stroke severe neurolic deficit
(7)
stroke,
collateral circulation,
cardiorespiratory function
, (1,8,9)
intermediate neurologic syndrome
reversible ischemic neurologic dificit (RIND)
TIA 24
stroke-in-evolution stuttering stroke
baseline
stepwise progressive
evolution crescendo TIAs (10)
stroke


2. VERTEBROBASILAR INSUFFICIENCY
vertebral artery 2-5
cerebrovascular occlusive disease VBI
cerebellum VBI
subclavian steal syndrome vertebral (11)
VBI vertigo, ataxia, paresis, numbness, dysphasia, dysarthia diplopia 5

VBI TIA steal
shunt middle cerebral artery
vertebral carotid artery occlusive disease
duplex ultrasonography arteriography
subclavian vertebral artery
VBI
posterior circulation 85
carotid vertebral occlusive disease
direct vertebral artery reconstruction
vertebral artery carotid artery
(12)
subclavian steal syndrome
proximal vertebral artery
subclavian innominate
reverse flow vertebral artery

carotid-subclavian bypass

3. ASYMPTOMATIC CONTRALATERAL
ARTERY STENOSIS

carotid endarterectomy TIA
stroke

80(13,14)
5-7
95
CEREBROVASCULAR DISEASE
4. ASYPTOMATIC ULCERATED LESIONS

plaque ulceration plaque
homogeneous heterogeneous

arteriography
stenotic area
5. ASYMPTOMATIC HOLLENHORST
PLAQUE
asymptomatic Hollenhorst plaque (cholesterol embolus retinal arteriole)
retinoscopy
transient fixed
retinal cerebral symptoms screen
duplex scan high-grade stenosis (>80%)

15
6. PULSATILE MASS

true aneurysm, carotid body tumors, lymphadenopathy
tortuous carotid artery sonography,
CT scan Magnetic Resonance Imaging (MRI)

carotid aneurysm
, cerebral embolization, thrombosis
,
end-to-end anastomosis interposition graft
carotid body tumor

7. ASYMPTOMATIC CERVICAL BRUITS

cervical bruit

cerebrovascular noninvasive testing
arteriography
asymptomatic carotid stenosis
10-33 asymptomatic cervical bruit
direct continuous-wave Doppler(2)
8. CAROTID FIBROMUSCULAR
DYSPLASIA (FMD)
benign disease
ischemic infarction carotid FMD
TIAs stroke atherosclerotic carotid occlusive disease
FMD internal carotid dissection

high-grade symptomatic FMD stenosis
internal carotid artery
aneurysm vein graft
interposition
9. SUBCLAVIAN STEAL SYNDROME

Left subclavian stenosis occlusion
atheroclerosis
(brachial pressure)
left arm claudication
collaterals
proximal left subclavian artery
subclavian steal syndrome
, , ataxia syncope
retrograde flow
left posterior cerebral circulation left vertebral artery
distal subclavian artery
intermittent posterior cerebral ischemia
96
classic subclavian steal syndrome
arteriography non-invasive evaluation carotid
system left subclavian stenosis
collateral flow circle of Willis posterior brain
arm claudication carotid-subclavian,
subclavian-subclavian, subcla- vain-to-carotid transposition percutaneous transluminal angioplasty.
cerebravascular insufficiency

,
peripheral vascular disease (PVD)(15,16)
carotid, superficial temporal, subclavian
radial carotid pulse
aortic arch
2
subclavian innominate artery bell stethoscope bruits carotid artery, , ,
supraclavicular region
,
intracranial
lesions CSF

CT scan stroke
cerebral infarction, ,

MRI
CT scan
positron emission tomography (PET)
single position emission computed tomography (SPECT)
ischemic infarcted cerebral tissue
Non-invasive Studies
noninvasive methods

extracranial circulation
asymptomatic carotid lesions
invasive arteriography
Oculopneumoplethysmography (OPG-Gee)
opthalmic artery common carotid artery internal carotid stump pressure
collateral flow cerebral hemisphere screening method (16)
Oculoplethysmography (OPG-Kartchner)
timing ocular pulse wave 2
hemodynamic internal carotid artery(17) carotid phonoangiography (CPA)
arteriography
85 OPG-Gee OPGKartchner
noninvasive test cerebrovascular disease duplex scan real time Bmode scanning doppler sound spectral analysis(18) ( 10.1) duplex scan
carotid blood flow
B-mode
image plaque soft,
dense, calicified,
duplex scan arteriography
carotid endarterectomy 2
Arteriography
definitive diagnostic procedure
4-vessels aortic arch ( 10.2) serial
biplane cervical intracranial vessels(19) computed digital subtraction arteriography (DSA)
conventional arteriography

97
10.1 Grag scale images Duplex scan, Color flow images Doppler waveforms
. normal internal carotid artery
. 50% stenosis of the internal carotid artery
. 90% stenosis of the internal carotid artery
0.2-1% stroke,
TIA stroke arteriography noninvasive test
duplex scan noninvasive studies

10.2 Cerebral angiogram high grade right
internal carotid artery stenosis irregularity
wall right common carotid artery
98
Transcranial Doppler Studies (TCD)

noninvasive study
collateral circulatin
flow velocity
carotid endarterectomy(20) TCD
intracerebral blood flow collateralization
degree of cerebral ischemia extracranial cerebrovascular disease velocity
middle cerebral artery stump pressure, EEG, shunt fraction,
carotid endarterectomy TCD

(antiplatelets)(21,22)
1. Aspirin

TIAs non disabling stroke
atheroclerotic plaque

cyclo-oxygenase inhibitor

American Aspirin Study Canadian Aspirin Study
stroke Dipyridamole platelet suppresant

325
90 prostacycline

2. Ticlopidine
ticlopidine hydrocloride
pathway
adenosine diphosphate
inhibit cyclo-oxygenase pathway

thromboxane prostacycline
ticlopidine

ticlopidine
stroke,

stroke (23,24)
1.

2.
transient cerebral ischemia
stable stroke,
asymptomatic stenosis cerebral ischemia(25,26) (
10.1)
stroke
underlying disease
(27)
10.1
Indications for Carotid Endarterectomy in
Cerobrovascular Insufficiency
Indications
Transient cerebral ischemia
Stable strokes (selected)
Asymptomatic stenoses (selected)
Chronic cerebral ischemia (selected)
Contraindications
Acute profound strokes
Progressing strokes
Severe intracranial disease
Other severe generalized disorders (e.g. cancer)
extracranial cerebrovascular disease

vertebral subclavian
artery.
I.

anticoagulant 24
multiple recent TIAs severe carotid stenosis (<2 mm)

(5% dextrose in Ringers
solution) 100-125
narcotic
arterial line
Swan-Ganz
II.

regional anesthesia (regional cervical block)

plaque atheroemboli (
10.3)
(
10.4)
1. ansa cervicals (hypoglosis)

99
2. hypoglossal nerve
bifuracation

hypoglossal nerve injury

hypoglossal
3. vagus nerve posterior carotid sheath

anterolateral surface
vagus nerve

3.1 vagus nerve

recurrent laryngeal
nerve vagus nerve
vocal cord tracheoesophageal groove recurrent laryngeal nerve subclavian
artery vagus nerve
3.2 superior laryngeal nerve carotid

biturcation vocal cord
cricothyroid

external carotid superior thyrodal arteries

4. greater auricular nerve sensory nerve
mastoid process, concha auricle
ear lobe anterior surface
sternocleidomastoid

5. mandibular branches facial nerve angle
of mandible mandible

100
Circle of Willis
Carotid syphon
Basilar artery
Left internal carotid artery
Right internal carotid artery
Left vertebral artery

Facial artery
Right external carotid artery
Lingual artery
Superior thyroid artery
Right subclavian artery
Left common carotid artery

Left vertebral artery
Left subclavian artery
Innominate artery
Hypoglossal (XII) n.
Ascending cervical a.
Facial a.
External carotid a.
Sternocleidomastoid m.
(cut edges)
Lingual a.
Superior thyroid a.
Internal carotid a.
Vertebral a.
Common carotid a.
Cerebral blood supply
10.3
.
.
101
Nodose ganglion
Glossopharyngeal nerve
Superior laryngeal nerve
Herings nerve
Vagus nerve
Hypoglossal nerve
Internal laryngeal nerve
External laryngeal nerve
Ansa cervicalis
Recurrent laryngeal nerve
10.4
III. thromboemboli

1. carotid bifurcation
ulcerated atheromatous plaque
2. clamp 5000
5
3.
heparinized saline
atheroma
shunt
4. endarterectomy surface
thromboembolism
low melecular weight Dextran recovery room antiplatelet anticoagulant 100 20

5. flush out
loose atheromatous
external carotid
artery flush
internal carotid artery.
IV.
2
shunt carotid endarterectomy(28)
10.5 (EEG) carotid endarterectomy
102
1. cerebral perfusion systemic blood pressure clamping carotid artery

(EEG)
diffuse slowing pattern (29) ( 10.5)
2. shunting carotid endarterectomy
shunt 1-3

cerebral perfusion clamp carotid artery stump pressure(30)
(EEG) (31)
shunt monitor EEG
carotid stump pressure 50

shunt
shunt

V. carotid endarterectomy
carotid reconstruction

( 10.7)
primary closure
repeated endarterectomy patch angioplasty monitor blood
flow continuous-wave Doppler probe,
arteriography B-mode ultrasound
10.6 carotid endarterectomy

. Pruitt - Inahara shunt
. carotid endarterectomy shunt
. carotid endarterectomy specimen ulcerated plaque thrombus
fibrin, platelet aggregates atherosclerotic debris
. arteriotomy site running suture patch angioplasty
103
VI.

,
fine hand movement

(32,33)
1. cardiorespiratory status
, ,
2.
2.1 contralateral hemiparesis

endarterectomy

arteriography duplex ultrasound
thrombi residual plaque
2.2 diffuse neurologic deficit internal capsule stroke
patency
OPG
ultrasonography

CT
scan 24 cerebral
infarction
10.7 carotid endarterectomy shunt
12-24

monitor vital signs 30-45

24 5% D/W
half strength NSS 1
hyponatremia
carotid endarterectomy carotid barorecoptor trauma
hypoxia monitor
, respiratory distress

hypoxia (PO2 < 60 mmHg) blood gas low molecular

weight Dextran
80-325
2-3
7
OPG
3-6
104
(32)
I.
TIA
CT scan

20

nitro- prusside

7-14

pseudoaneurysm
cranial nerves
5-20
hypoglossal recurrent laryngeal nerves
1/3
recurrent laryngeal nerve injury direct laryngoscopy
2-6
II.
recurrent carotid stenosis 1-3
10-20
noninvasive carotid tests(34)
stroke
origin
internal carotid artery carotid endarterectomy early stenosis neointimal
FMD surface thrombus late restenosis atherosclerosis carotid arteriography carotid endarterectomy patch
angioplasty(35,36)
carotid pseudoaneurysm
mural thrombus
pseudoaneurysm
atherosclerotic occlusive disease extra cranial

carotid artery
stroke
noninvasive tests oculoplethysmography, duplex
scan, Transcranial Doppler Studies (TDS), magnetic resonance arteriography (MRA)
arteriography
noninvasivests follow up
TIA
high-grade stenosis (70%)

monitor EEG shunt
cerebral
infarction
limited life
expectancy
lesion

, ticlopidine
carotid endarterectomy stroke

, ,

105
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11
2
(1,2)
( 11.1)
1.
innominate subclavian, axillary brachial

2.

digital connective tissue disease

arteriosclerosis
vibratory white finger(3)

ulnar hypothenar hammer syndrome

Thoracic Outlet Syndrome (TOS) subclavian cervical rib

subclavian axilla(4,5)
dopamine
ergot 11.1

brachial

Raynauds phenomenon

(pallor)
(blue) (redness)

11.2 acrocyanosis
108
Deep cervical
Vertebral
Transverse scapular
Axillary
Thyrocervical trunk
Common carotid
Posterior humeral circumflex
Subclavian
Interior thoracic (mammary)
Anterior humeral circumflex
Supreme thoracic
Thoracoacromial
Brachial
Lateral thoracic
Subscapular
Profunda branchii
Superior ulnar collateral

Inferior ulnar collateral
Radial recurrent
Elbow
Common interosseous
Dorsal interosseous
Radial
Ulnar
Volar interosseous
Deep volar arch
Superficial volar arch
Digital
11.1 collaterals
diffuse cyanosis
livedo reticularis

(mottled cyanosis) 3 11.3

11.1
Atherosclerosis

Antiphospholipid syndrome
(arteritis)
1. Collagen disease
dermatomyositis
rheumatic arteritis
scleroderma
systemic lupus erythematosus (SLE)
2. Allergic Necrotizing arteritis
3. Giant cell arteritis
4. Takayasus disease
Bechets syndrome
cold agglutinins
cryoglobulins
polycythemia vera
Thoracic outlet syndrome (TOS)
Congenital arterial wall defects
Ehlers-Danloss syndrome
Pseudoxanthoma elasticum
Fibromuscular dysplasia
Frosbite
Iatrogenic injury
arteriography
cardiac catheterization

azotemic arteritis hemodialysis
shunt
109
Raynauds disease Raynauds phenomenon
underlying cause
11.1
( 70)
Raynauds disease
1. Raynauds phenomenon

2.
3.
4. 2 systemic disease
Raynauds phenomenon

livedo reticularis

aneurysm
subclavian axillary ( 11.2)
11.2 Raynauds phenomenon

Systemic disease
Collagen vascular disease sclerodema
Cold hemagglutinin cryoglobinemia
Myxedema
Ergotism
Macroglobulinemia
Nerve compression
Carpal tunnel syndrome
Thoracic outlet syndrome (TOS)
Occupational trauma
Pneumatic hammer operation
Chainsaw operation
Piano playing
Typing
Arterial occlusive disease
110
11.3 vasospastic disease
Raynauds phenomenon
Acrocyanosis
Livido reticularis
70-80
(15-35 )
Pallor, cyanosis, rubor
,

collagen vascular
disease scleroderma
90
(15-35 )
Diffuse cyanosis
,
Mottle cyanosis or rubor

Thoracic outlet syndrome

supraclavicular aneurysm cervical rib
midclavicular bruit
neutral, abduction, external rotation
hyperabduction
Allens test radial ulnar capillary refilling time
6

11.2 microemboli aneurysm
subclavian axillary

noninvasive Doppler wave form analysis segmental arterial pressure brachial pressure
1020 subclavian, axillary brachial finger pressure
15
palmar arch
111
Duplex US color-coded mode

velocity image aneurysm, AVF

CRCT
syndrome (Calcinosis, Cutis, Raynauds phenomenon, Sclerodactyly, Telangiectasia)
azotemic arteriopathy
TOS cervical rib ( 11.3)

clavicle scleroderma pulmonary
fibrosis

systemic disease

1. ESR (erythrocyte sedimentation

rate)
2. ANA (antinuclear antibodies)
3. C3/C4 complement test
4. rheumatoid factor

Raynauds phenomenon Raynauds disease
1.
1.1 Atherosclerosis
subclavian innominate

vertebral artery steal ulcerative plaque

11.3 . cervical subclavian

. arch arteriography subclavian
112
1.2 (arteritis) Takayasus, giant
cell arteritis, temporal arteritis polymyalgia
rheumatica
Takayasus arteritis nonspecific inflammatory process aorta
carotid, subclavian,
axillary pulmonary 1030 arteriography
collaterals
pulmonary artery 45
Giant cell arteritis
cranial, temporal
subclavian axillary
50 temporal artery
ESR 50m/SEC arteriogram

Temporal arteritis polymyalgia rheumatica

subclavian axillary
1.3 Thoracic outlet syndrome (TOS)

1.3.1 costoclavicular space

clavicle
1.3.2 anterior scalene muscle
1.3.3 insertion pertoralis minor tendon coracoid process axilla
1.3.4 humerus head external rotation
thoracic outlet
cervical rib hypertrophy
scalene muscle

axillary artery circumflex humeral artery aneurysm
aneurysm,
poststenotic dilatation, thrombosis distal embolization Raynauds phenemenon

1.4 Radiation injury
Hodgkins disease
subclavian axillary
artery 3 (6)
1)
internal elastic lamina fibrosis media
2) vasa vasorum
hyalin intima
fibrosis media
3) periarterial fibrosis

4
1. necrosis
2. mural thrombosis
thromboembolism 5
3. fibrotic occlusion
10
4. 20 periarterial fibrosis accelerated atherosclerosis

arteriogram diffuse long narrowing
1.5 Fibromuscular dysplasia

brachial

nonarteriosclerosis noninflammatory vascular disease
113
2.
2.1 scleroderma,
rheumatoid arteritis SLE, polyarteritis nodosa
dermatomyositis
Raynauds phenomenon

palmar arch
2.2 Buergers disease (Thromboangiitis Oblitrans
TAO)

migratory thrombophlebitis
arteriogram
2.3 Blood dyscrasia cold agglutinin, cryglobulin

polycythemia vera

local thrombosis
2.4

radial brachial
2.5 Vibration syndrome

digital artery
2.6 Hypothenar hammer syndrome

ulnar hypothenar eminence
aneurysm
aneurysm

2.7 Calciphylactic arteriopathy

(pipe
stem pattern)
(embolectomy)

Urokinase Streptokinase
Thrombolytic therapy

Fogarty catheter corticosteroid

calcium blocker (Nifedipine)

subclavian artery aneurysm TOS aneurysm cervical rib
bypass autogenous vein graft
radial ulnar artery
thrombectomy endarterectomy patch
angioplasty
bypass

major amputation

114
1. Fugitani RM, Mills JL. Acute and chronic upper extremity ischemia
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(eds.). Basic Data Underlying Clinical Decision Making in Vascular
Surgery. St Louis: Quality Medical Publishing 1994;159-165.
2. Mills JL, Fugitani RM. Acute and chronic upper extremity ischemia
II. Small vessel arterial occlusive disease. In: Porter JM, Taylor LM.
(eds.). Basic Data Underlying Clinical Decision Making in Vascular
Surgery. St Louis: Quality Medical Publishing 1994;166-170.
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4. McCarthy WJ. Upper extremity arterial injury in athletes. J Vasc
Surg 1989;9:317.
5. Rohrer MJ. Axillary artery compression and thrombosis in throwing
athletes. J Vasc Surg 1990;11:761.
6. Butler MS, Lane RHS, Webster JHH. Irradiation injury to large arteries. Br J Surg 1980;67:341.
12
ABDOMINAL AORTIC
ANEURYSMS (AAA)
Aneurysm
2

4 (1)
bilateral popliteal aneurysms AAA
69 femoral artery aneurysms iliac aneurysms
AAA 92 70 (1,2,3) AAA
renal artery 2
renal visceral arteries

asymptomatic AAA
AAA

screen
retroperitoneal

monitor

infrarenal AAA atherosclerosis intimal degenerative process

aorta
medial structural proteins proteolytic enzymes
nonspecific arteriopathy vasa vasorum
aorta

(4,5,6) ( 12.1)
Genetic abnormality
in collagen
Atherosclerotic damage
to elastin and collagen
Aging and natural

degeneration of elastin
Increased proteolytic
enzyme activity
12.1
arterial aneurysms
116
AAA

connective tissue(4,7)
AAA
elastase alpha-1-antitrypsin
(elastase inhibitor) collagen
AAA atheroclerosis
AAA
(salmonella syphilis)
connective tissue Ehlers-Danlos Marfans
syndrome (8,9,10,11)
AAA
Society for Vascular Surgery International Society for
Cardiovascular Surgery atherosclerotic AAA
nonspecific AAA
75 infrarenal AAA

80
AAA aortic bifurcation epigastrium
DeBakeys maneuver AAA renal arteries AAA tortuous aorta
AAA

tortuous aorta
transmitted pulse
aorta pancreatic mass
radiated expansile pulsation
infrarenal AAA ,
, AAA
aorta
AAA

distal embolization(12)
AAA
triad

ruptured AAA
, pancreatitis renal colic(13) AAA left retroperitoneal peritoneal cavity AAA

duodenum mucosa duodenum
aorto-duodenal fistula
duodenum 4th part
fistula aortocaval fistula
abdominal bruit, venous hypertension,
(14)
AAA distal embolization aortic debris aortic thrombosis(12)
vertebral erosion
ureter
screening
AAA

aorta screening test ,
noninvasine, , ionizing
radiation nephrotoxic agents
(15-17)
1. plain abdominal film calcified aneurysmal wall ( 12.2)
2. B-mode ultrasonography AAA
100% ( 12.3)
,
AAA
screening test
follow up AAA
3. computed tomography (CT) scan
AAA ,
117
ABDOMINAL AORTIC ANEURYSMS (AAA)
12.2 plain abdominal film calcified aneurysmal wall
12.3 ultrasonography
abdominal aortic aneurysms
12.4 CT scan abdomen

leakage aortic
aneurysms

118
, ,
degree calcified aortic plaques
, extravasation
ruptured leakage AAA ( 12.4)
retroperitoneal
fibrosis inflammatory AAA

4. aortography conventional digital biplane aortography
AAA (
12.5) aortography
AAA
renal arteries, iliofemoral arteries
luminal thrombus
AAA contrast-enhanced CT complements aortography aortography , ,
preoperative aortography
4.1 thoracoabdominal aortic aneurysm
4.2 renovascular hypertension
4.3 AAA renal arteries
4.4 visceral angina

4.5 bruit
4.6 femoral pulse
4.7 peripheral vascular occlusive disease
4.8 horseshoe Kidney
4.9 chronic aortic dissection
4.10 iliac artery aneurysm
4.11 colectomy
aneurysmorrhaphy colonic circulation intestinal ischemia
5. magnetic resonance arteriography spiral

CT scaning noninvasive diagnostic test
,
12.5 Transfemoral aortography

aneurysms

AAA thrombosis
distal embolization AAA
fistula vena cava duodenum 75 AAA

AAA

AAA
(18,19)
AAA
4 15 5 8
75 AAA
5-6 (19,21,22)
elective
AAA
(23)
119
1. AAA 4
2.
3. generalized ectasia
4. COPD
ruptured AAA
45
10 elective aneurysmorrhaphy
3-5 underlying
diseases (22)
AAA 5
elective
AAA (22)
1. recent multiple myocardial

infarction,
2. COPD

dyspnea at rest
4. metastatic cancer limit life expectancy

elective

coronary heart disease (CAD)
AAA 20 CAD
50 AAA
30
myocardial infarction(24,25)
CAD AAA
preoperative noninvasive cardiac evaluation
(26,27,28)
1. dipyridamole scan
2. echocardiography
3. ejection fraction evaluation
4. cardiac catheterization
AAA
AAA
1. recent MI
2. inoperable CAD
3. end-stage pulmonary disease
4.
AAA

AAA 25
(29)
1. external aneurysm wrapping
2. extra-anatomical bypass with ligation of the aneurysm
2 AAA

intensive care monitor
intraluminal AAA
( 12.6) , ,
, iliac artery

(30) perigraft leakage 12
20 Endovascular Stent Grafting(31)

12.6 Endovascular Stent Grafting

femoral artery
120
AAA repair
invasive monitoring
line (pulmonary radial arterial catheters)
hemodynamic status

7

autotransfusion
midline AAA
retroperitoneal
oblique incision 11
rectus abdominis retroperitoneal approach
iliac artery renal arteries
retroperitoneal approach (32,33)
1. aneurysm right iliac artery

2. obesity
3.
pulmonary disease
4. colostomy
retroperitoneal approach

aorta
ICU

AAA 90 renal arteries

cross clamping aorta
AAA renal arteries cross clamp aorta
30

mannitol (35,36)
cross clamping iliac arteries

cross clamping aorta emboli debris
pre-clotting Dacron graft
cross clamping
AAA lumbar arteries inferior
mesenteric arteries meandering artery
Dacron
saccular aneurysm
aneurysm iliac arteries Y
graft Dacron graft pre-clotted aorta
iliac arteries clamps iliac arteries
aorta

declamping hypotension
aneurysmal sac
( 12.7)
AAA
Dacron graft
elective
pre-clotting

AAA
1-2
Steri-drape
contamination
ruptured AAA
pre-clotting Dacron
graft
Woven Dacron graft
impregnated Dacron graft
pre-clotting
(37)
pre-clotting
121
12.7 aneurysmorrhaphy Graft Interposition
. iliac aorta
inferior mesenteric artery (IMA)
. aneurysm thrombus back bleeding lumbar artery IMA
reimplantation
. Dacron graft aorta cross clamp aorta
distal anastomosis aneurysm reimplant IMA

Woven impregnated Dacron graft Dacron graft
2
Polytetrafluoroethylene (PTFE) graft
aorta
PTFE graft Dacron
graft 3
AAA
retroperitoneal approach
1. malignant tumor elective repair

4-5
AAA
,
AAA
2. asymptomatic gall stone 5-20
repair AAA contamination graft (38)
3. renovascular hypertension
renal artery stenosis
repair AAA
122
elective aneurysmal repair

1-5 (39,40)
myocardial dysfunction nonfatal MI 316(41)
venous injury IVC, left
renal vein iliac vein

reflex renal vasoconstriction, ,
intrarenal redistribution of blood flow, atheromatous debris renal artery, temporary
suprarenal aortic cross clamping aortic cross clamping
mannitol
renal complication

ileus colonic infarction(42) adynamic ileus
5 hematoma
duodenal obstruction pancreatitis hyperamylasemia
ischemic colitis
2 (43)
bowel ischemia bloody diarahea colonoscope
colonic mucosa peritonitis
proximal diverting colostomy
ischemic colitis investigate

90
lower extremity ischemia
distal embolization thrombosis
blood stasis, intimal flap crushed atherosclerotic plaque heparin cross
clamping aorta thrombosis hemostasis
thromboembolism thromboem-
bolectomy micro emboli

potches ischemia
trash foot
paraplegia spinal
cord ischemia thoraco abdominal aneurysm Radicularis artery (
Adam kevics artery)
neck aneurysm
cysterna chyli L2

recurrent bacteremia, false aneurysms, intraabdominal
infected collection graft-enteric fistula(44)
RUPTURED ABDOMINAL AORTIC

ANEURYSM (rAAA)
rAAA 100%
5080(45,46,47)
, respiratory failure multiple organ failure (MOF)
(48)
1.
triad
,
syncope pathognomonic signs

rAAA retroperitoneum
(49)
2.
leukocytosis

vital signs
123
2.1 Plain abdomen film widened and calcified

aorta psoas shadow
2.2 ultrasound

2.3 CT scan
2.4 aortography contamination

hemodynamic stable

blood chemistry
Group matching
CVP
(50,51,52)

ER thoracotomy cross clamp aorta

cell saver autologous blood
transfusion RBC, FFP, cryoprecipitate platelets
(heat loss
coagulopathy)
hemodynamic monitoring equipment

sympathetic tone
cross clamping aorta
midline
proximal distal control aorta iliac arteries
distal clamp control iliac
veins
Woven
Dacron graft coated graft

pre clotting

(53)

prolonged hypotension
coagulopathy, hypothermia circulatory
volume coronary
heart disease monitor Swan-Ganz
catheter
dialysis
ARDS CHF
lower extremity ischemia, ischemic
colitis
rAAA early recognition

80
(46-49,53)
abdominal aortic aneurysms

ultrasonography, CT scan spiral CT scan

ruptured abdominal aortic aneurysm
aneurysmorrhaphy
elective case retro
peritoneal
Endovascular
Stent Grafting
124
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36. Cohen JR, Mannick JA, Couch NP, et al. Abdominal aortic aneurysm repair in patients with preoperative renal failure. J Vasc Surg
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38. String ST. Cholelithiasis and aortic reconstruction. J Vasc Surg
1984;1:664-669.
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557 patients. Ann Surg 1983;197:49-56.
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43. Hagihara PF, Ernst CB, Griffen WO. Incidence of ischemic colitis
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125
44. Seabrook GR, Schmitt DD, Bandyk DF, et al. Anastomotic femoral
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126
13
AORTOILIAC OCCLUSIVE
DISEASE (AIOD)
Aortoiliac atherosclerosis
infrarenal aorta iliac arteries
arterial insufficiency atherosclerosis generalized process
aortoliac
femoral, popliteal tibioperoneal
arteries ( 13.1) 50-65
10 (1)
(2)
claudication

angioplasty
AIOD claudication
claudication AIOD
(3) calf claudication

inguinal region ( 13.2) claudication femoral impotence Leriches syndrome ( 13.1)
AIOD 75 claudication
25 threatened limb loss
ischemic rest pain, gangrene
( 65 ) underlying disease
COPD

AIOD blue toe syndrome
atheroemboli aortoiliac
atheroma
( 13.3 ..)
ulcerated aorta renal arteries
(4)
128
Type I
Type II
Type III
13.1 Aortoiliac occlusive disease (AOID)
Type I distal aorta common iliac arteries 13

Type II femoral arteries 20
Type III inguinal ligament 67
dication
Mild Clau
udication
Cla
Moderate
ion
udicat
Severe Cla
Ulcer
Rest-Pain
ion
Claudicat
13.2 claudication
collaterals collaterals gangrene
129
AORTOILIAC OCCLUSIVE DISEASE (AIOD)
13.3 . Ulcerated atheroma aortic aneurysm atheroemboli
. atheroemboli
blue toe syndrome
AIOD
doppler pressure
(5)
aortogram

bruit aorta femoral arteries
30-60
abdominal femoral bruits
pedal pulse

non-invasive hemodynamic testing

hemodynamic
ankle-brachial blood pressure index
(ABI) ABI 1.0
treadmill ABI
IC ABI 0.5-0.8 treadmill ABI treadmill excercise
claudication (, )
walking distance
(1,5) threatened limb loss
ABI 0.5 transcutaneous oxygen tension
20-30 blue-toe syndrome embolic occlusive disease ABI

(4,6)
130
Arm Blood
Pressure
115
130-
Arm Blood
Pressure
150
-80
150-
Arm Blood
Pressure
135
-120
135-
-135
120-
-75
120-
-115
135-
-60
115-
-70
120-
-115
80-
-60
13.4 segmental leg pressures

doppler pressures

duplex ultrasonography magnetic resonance (MR) scanning

(7,8)
impotence penile-brachial doppler pressure index (PBI) 0.7
vasculogenic erectile dysfunction treadmill exercise PBI
AIOD penile duplex sonography
venogenic arteriogenic impotence
ABI exercise
AIOD
aortogram
Arteriography
standard digital intra-arterial arteriography

( 13.5)
arteriogram

(9,10,11) arteriogram abdominal aorta
renal, mesenteric pelvic arteries biplane aortography
femoral axillary arteries(9,10,11)
oblique pelvic views iliac artery lateral
views celiac mesenteric arteries
persterior wall aorta femoral arteries
pressure gradients
arteriography 10 mmHg
hemodynamic
131

(12,13,14)
1. threatened limb loss rest
pain, foot sores, gangrene blue toe syndrome
2. disabling claudication
3. vasculogenic impotence
13.5 Transfemoral arteriography distal aorta

AIOD

70-80

hemorrheologic agents
pentoxifylline 8

(12)
1. stable claudication
aortoiliac femoropopliteal-tibial

2. life threatening condition
3.

1530
AIOD femoropopliteal-tibial disease
AIOD
15
AIOD
femoropopliteal-tibial coronary atherosclerosis 30(15,16)

(ejection fraction 35) COPD (FEV1 1
), ( 3.0
mg%) 710 2-7(17)
coronary heart disease
AIOD
(18,19) pro-
132
thrombolytic infusion therapy

hottip laser atherectomy device
stent (19) PTA
common iliac artery 3
run-off 5-year survival iliac arteries
60-70(14)
aorta external iliac arteries
2. Aortoiliac Surgical Reconstruction
13.6 common iliac

gressive unstable angina pectoris coronary angiography coronary bypass revascularization AIOD
MI stable angina pectoris cardiac stress
test
severe claudication dipyridamole thallium scan
coronary
angiography
non-invasive 24-hour
EKG monitoring ischemic ST-segment change

AOID
SPECIFIC INVASIVE THERAPIES

1. Percutaneous Transluminal Angioplasty
PTA
common iliac(10) ( 13.6)
advanced AOID
endarterectomy bypass grafting ( 13.7, 13.8)
2-3
5-10 (20-24)
claudication 95 5-year patency
aortofemoral bypass 80-90(20)
graft thrombosis, femoral
anastomotic pseudoaneurysm
renal visceral
arteries revascularization
AIOD
3. Extra-anatomic Surgical Procedure

axillofemoral femorofemoral bypass graft
AIOD(25,26,27)

direct aortoiliac aortofemoral
bypass ( 13.9)
graft thrombosis (24,26) femoro-femoral crossover bypass iliac artery
5-year graft patency 70-80(26,28)
axillofemorals bypass
aortoiliac reconstruction infected aortic graft adhesions

extraperitoneal approach(29) axillofemoral bypass 5-year
patency 50-80 femoropopliteal runoff
(25)
133
13.7 . aortoiliac reconstruction

abdominal aorta
. Endarterectomy
. Aortic bypass grafting
aortoiliac
reconstruction
13.8 Transabdominal aortobifemoral bypass
elective aortoiliac reconstruction

(30)
aortic grafting ( 6-9 3)
(31) cholecystectomy herniorrhaphy

cholecystectomy cholecystitis
aortic reconstruction retroperitoneal
approach cholecystectomy

aortic
reconstruction
134
13.9 . Axillobifemoral bypass graft

. Crossover femorofemoral bypass graft
. Unilateral iliofemoral bypass graft
135
PTA aortoiliac
reconstruction

6-8 ankle Doppler pressure

false aneurysm
MI, arrhytmia

atherosclerosis

AOID

PTA
common iliac artery endarterectomy bypass graft
underlying disease
136
1. McDaniel MD, Cronenwett JL. Basic data related to the natural

history of intermittent claudication. Ann Vasc Surg 1989;3:273277.
2. Couch NP. On the arterial consequences of smoking. J Vasc Surg
1986;8:303-317.
3. Goodreau JJ, Creasy JK, Flanigan DP, et al. Rational approach to
the differentiation of vascular and neurogenic claudication. Surgery 1978;84:749-757.
4. Baumann DS, McGraw D, Rubin BG, et al. An institutional experience with arterial atheroembolism. Ann Vasc Surg 1994;8:258-265.
5. Carter SA, Hamel ER, Paterson JM, et al. Walking ability and ankle
systolic pressures: observations in patients with intermittent claudication in a short-term walking exercise program. J Vasc Surg
1989;10:642-649.
6. Karmody AM, Powers FR, Monaco VJ, Leather RP. Blue toe
syndrome: an indication for limb salvage surgery. Arch Surg
1976;111:1263-1271.
7. Owen RS, Carpenter JP, Baum RA, et al. Magnetic resonance
imaging of angiography occult runoff vessels in peripheral arterial
occlusive disease. NE J Med 1992;326:1577-1581.
8. Picus D, Hicks ME, Darcy MD, et al. Critical review of: Magnetic
resonance imaging of angiographically occult runoff vessels in peripheral arterial occlusive disease. J Cardiovasc Surg 1991;32:8186.
9. Rubin GD, Walker PJ, Dake MD, et al. Three-dimension spiral
computed tomographic angiography: An alternative imaging modality for the abdominal aorta and its branches. J Vasc Surg
1993;18:656-665.
10. Van Andel GJ, van Erp WFM, Krepel VM, et al. Percutaneous
transluminal dilatation of the iliac artery: Long term results. Radiology 1985;156:321-323.
11. Brewster DC, Cambria RP, Darling RC, et al. Long term results of
combined iliac balloon angioplasty and distal surgical
revascularization. Ann Surg 1989;210:324-331.
12. Porter JM, Cutler BS, Lee BY, et al. Pentoxifylline efficacy in the
treatment of intermittent claudication: Multicenter controlled doubleblind trial with objective assessment of chronic occlusive arterial
disease patients. Am Heart J 1982;104:66-72.
13. Brewster DC, Perler BA, Robison JG, Darling RC. Aortofemoral
graft for multilevel occlusive disease: predictors of success and
need for distal bypass. Arch Surg 1982;117:1593-1600.
14. Johnston KW, Rae M, Hogg-Johnston SA, et al. Five-year results of
a prospective study of percutaneous transluminal angioplasty. Ann
Surg 1987;206:403-413.
15. Hertzer NR. Basic data concerning associated coronary disease in
peripheral vascular patients. Ann Vasc Surg 1988;1:616-620.
16. Taylor LM Jr, Yeager RA, Moneta G, et al. The incidence of

perioperative myocardial infarction in general vascular surgery. J
Vasc Surg 1991;15:52-61.
17. Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in
peripheral vascular patients: a classification of 1000 coronary
angiograms and results of surgical management. Ann Surg
1984;199:223-224.
18. Freeman WK, Gibbons RJ, Shub C. Preoperative assessment of
cardiac patients undergoing noncardiac surgical procedures. Mayo
Clin Proc 1989;64:1105-1117.
19. Weibull H, Bergqvist D, Jonsson K, et al. Complications after percutaneous transluminal angioplasty in the iliac, femoral and popliteal
arteries. J Vasc Surg 1987;5:681-686.
20. Golden MA, Whittemore AD, Donalson MC, et al. Selective evaluation and management of coronary artery disease in patients undergoing repair of abdominal aortic aneurysms: A 16-year experience. Ann Surg 1990;212:415-423.
21. Naylor AR, Ah-See AK, Engeset J. Aortoiliac endarterectomy: An
11-year review. Br J Surg 1990;77:190-197.
22. Inahara T. Eversion of endarterectomy for aortoiliac occlusive disease. Arch Surg 1975;110:1458-1464.
23. Van den Akker PJ, van Schilfgaarde R, Brand R, et al. Aortoiliac
and aortofemoral reconstruction of obstructive disease. Am J Surg
1994;167:379-385.
24. Szilagyi DE, Elliott JP Jr, Smith RF, et al. A 30-year survey of the
reconstructive treatment of aortoiliac occlusive disease. J Vasc
Surg 1986;3:421-436.
25. Donaldson MC, Louras JC, Bucknam CA. Axillofemoral bypass: A
tool with a limited role. J Vasc Surg 1986;3:757-763.
26. Fahal AH, McDonald AM, Marston A. Femorofemorals bypass in
unilateral iliac artery occlusion. Br J Surg 1989;76:22-29.
27. Harris EJ Jr, Taylor LM Jr, McConnell DB, et al. Clinical results of
axillobifemoral bypass using externally supported
polytetrafluoroethylene. J Vasc Surg 1990;12:416-421.
28. Kalman PG, Hosang M, Cina C, et al. Current indications for
axillounifemoral or axillofemoral bypass grafts. J Vasc Surg
1987;5:828-835.
29. Sicard GA, Freeman MB, Vandar Woude JC, et al. Comparison
between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal aorta. J Vasc Surg 1987;5:19-27.
30. Franko E, Cohen JR. General surgical problems requiring operation
in postoperative vascular surgery patients. Am J Surg 1991;162:247250.
31. Pitt HA, Postier RG, MacGowan WAL, et al. Prophylactic antibiotics in vascular surgery. Ann Surg 1980;192:356-364.
14
Intermittent
Claudication (IC)

IC
(1,2) IC
atherosclerosis
(2) IC
hypoxemia anemia
(3)
IC
ankle-brachial index (ABI)
(4)
ABI ABI
(5) exercised ABI
collaleral circulation(4,5)
IC 1520(6,7)
(6,7,8,9)

ABI 0.55(10)
1. atherosclerosis

hyperviscosity

(8)
IC 214-300(9)
2.
collaterals
arteriovenous
O2 gradient
toxic metabolites ischemic pain
postexercise hyperemia
(5,10-12)

3.
IC ( 14.1)
138
14.1 Intermittent claudication (IC)
Anticoagulants
Vasodilator
Cyclandelate
Ethaverine
Isoxuprine
Nicotinic acid
Papaverine
Phenoxybenzamine
Tolazoline
Prostaglandins
PGE1
PGE2
Antiserotonin agents
Ketanserin
Metabolic enhancers
Naftidofuryl
Antiplatelet agents
Aspirin
Dipyridamole
Sulfinpyrazone
Sulotidil
Ticlopidine
Calcium-channel blocking agents
Cinnarizine
Darodipine
Flunarizine
Verapamil
Hemorrheologic agents
Buflomedil
Dextran
Pentoxifylline
(13,14) calcium channel blocker

(15,16,17)
pentoxifylline
hemorrheology(18-23)
atherosclerosis
(24)
thrombus Warfarin (Vit K antagonist)

norepinephrine, epinephrine serotonin
prostacycline endothelium derived relaxation factors en-
dothelium-1
norepinephrine

anaerobic metabolism
steal phenomenon

(25)

IC

atherosclerosis

serotonin mitogenic
(platelet-derived growth factor)
atherosclerosis
atherosclerosis(26)
Aspirin, Sulfinpyrazole
Dipyridamole Aspirin (irreversibly) Sulfinpyrazole (reversibly) cyclo-oxygenase
postanoids arachidonic acid
(thromboxan A2 prostacycline) Dipyridamole
phosphodiesterase cyclic
adenosine monophosphate (cAMP)

prostacycline (PGI2) IC

Aspirin Dipyridamole

Thromboxane synthetase inhibitors imidazole
compounds
139

arachidonic acid PGI2
IC
Aspirin
Sulotidyl platelet thrombogenic activity
Ticlopidine
platelet membrane adenosine diphosphate (ADP) receptor
IC

IC
Aspirin 325
Prostaglandins
PGE1 PGE2
half life
(27)
ischemic ulcer placebo(28)

Naftidrofuryl (Praxilene)

Kreb cycle ATP IC

ischemic rest pain tissue oxygenation(29)
Carnitine aerobic metabolism
Kreb cycle long-chained fatty acid
ATP
carnitine
IC

ATP (30)
Antiserotonin drugs
serotonin
inflammatory response Ketanserin
serotonin antagonist Serotonin S-2 receptor blocker

IC(31)
Calcium-channel blockers

IC
(15,16,17) Verapamil

Dazopidine dihydropyridine
Cinnarizine
Flunarizine IC
hemorrheology
Hemorrheologic agents
Dextran

microcirculation(18)
IC

8
5-6

anaerobic
hyperosmolality
hemorrheologic agents (19)
140
Pentoxifylline xanthine

microcirculation
Ehrhy

oxygen
tension (20,21)
Pentoxifylline IC

10
IC
pentoxifylline
10-12 (20-23)
Intermittent claudication 15-20

80
55-60
collateral circulation

development atherosclerosis
hemorrheologic agents pentoxifylline

anticoagulants
intimal hyperplasia
141
1. Imparato AM, Kim G, Davidson T, et al. Intermittent claudication:

Its natural course. Surgery 1975;78:795-799.
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history of intermittent claudication. Ann Vasc Surg 1989;3:273277.
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Philadelphia: American College of Clinical Pharmacology 1983;4352.
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claudication:current results of nonoperative management. Arch
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skeletal muscles from patients with peripheral arterial insufficiency.
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1986;3:374-381.
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treatment of intermittent claudication: multicenter controlled doubleblind trial with objective assessment of chronic occlusive arterial
disease patients. Am Heart J 1982;104:66-72.
21. Grean RM, McNamara J. The effects of pentoxifylline on patients
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142
15

monitor
25-33
monitor
cardiovascular

self-retaining retractor

retractor
retractor

monitor
central monitoring central venous pressure

(CVP) Swan-Ganz catheter monitor hemody-
namic fluid status CVP systemic

venous pressure right atrium
SVC right
atrium CVP right atrial filling pressure
right ventricular performance pulmonary arterial diastolic (PADP) pulmonary capillary wedge pressure
(PCWP)
fluid status CVP Swan-Ganz
(jugular
subclavian veins) pulmonary
artery Swan-Ganz cardiac output, mixed
venous (pulmonary arterial) oxygen saturation volume status aorta
bypass
Swan-Ganz 12-24


Swan-Ganz
Arterial lines

144
blood gases
carotid aorta
arterial lines radial artery
Allens test radial ulnar artery arterial line
brachial artery
collaterals
monitor EKG

pulse oximeter arterial oxygen saturation
monitor urine output
NG tube
retroperitoneum

postoperative ileus
15.1

Betadine
Betadine

carotid artery
, clavicle,
common carotid artery (CCA),
internal carotid artery (ICA) external carotid artery
(ECA) clavicle
( 15.1) steri-drape
15.2

axillofemoral bypass
145
15.3
axillofemoral bypass
clavicle,
clavicle, , ,
steri-drape (
15.2)

thoracoabodominal aorta
retroperitoneal approach of the aorta
right lateral decubitus
femoral arteries
brachial nerve palsy
( 15.3)

pubis
abdominal aorta

thoracoabdominal aorta
retroperitoneal aorta
( 15.4)
bypass

external iliac femoral
arteries
greater saphenous
vein
cephalic vein basilic vein
Mechanical Assistants
mechanical retractor robot retractors
continous exposure operative field

146
15.4
Omni retractor
abdominal aorta
15.5

abdominal aorta
147
operative field Omni

retractor abdominal aorta
( 15.5)
Single-armed robot retractor expose
corotid artery, distal external iliac proximal common femoral arteries
abdominal aorta
epidural spinal anesthesia cardiac stress
regional anesthesia
carotid artery regional anesthesia

Heparin

thoracoabdominal aneurysm anticoagulant effect monitor activated clotting time (ACT) partial thromboplastin time (PTT)
anticoagulant effect
ACT test
10 ACT

200-250 ( 150 ) ACT
150 bolus dose 100 /
1 1000
ACT
thrombosis

hypercoagulable
states ACT
antithrombin III
antithrombin III clotting factors
ACT ACT
antithrombin III

arterial thrombosis hypercoagulable state heparin-induced-thrombocytopenia (HIT)
Protamine
reverse anticoagulant effect

1 100
30 0.5 100
30 -

INH allergic reaction (The P in INH strands for
protamine)

1st generation cephalosporin
cefazolin 1 30
4
contamination 8 48
foot infection cefozolin local wound
irrigation

clamp pack
thrombin, Gelfoam, Avitene Surgicel Surgicel

148
wound dehiscence
carotid endarterectomy sternomastoid
plastysma
skin
staples
subcuticular sutures
fascia, subcutaneous
crural fascia,
Scarpas fascia, subcutaneous tissue

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1987;74:22.
16
RENOVASCULAR
HYPERTENSION

atherosclerosis

malignant hypertension
cerebrovascular accident
ischemic nephropathy

end-stage renal failure 5-15
(1-4)
retropertoneum
aorta
superior mesenteric artery (SMA) L1 - L2
25 renal arteries
2 aorta
T12 common iliac artery (CIA)
main renal artery 5 extra parenchymal segmental artery (apical upper, middle, lower
posterior) segmental arteries

lobar interlobar arteries
pyramids interlobar arteries
arcuate artery cortex medulla arcuate artery interlobular artery, intralobular artery afferent
glomerular arteriole renal vein artery
aorta superior mesenteric artery IVC 3 left renal
vein gonadal, adrenal posterior lumbar vein
posterior lumbar vein
mobilize renal vein 3
75
atherosclerosis (orifice)(5,6)
fibromuscular dysplasia (FMD) dysplastic
fibrosing lesions intima, media adventitia(7,8) medial FMD
angiogram string bead FMD
(8)

RVH aneurysm, emboli, traumatic lesion arteriovenous fistula
150

vasomotor tone
RVH
renin angiotensin -aldosterone system(1,4,9,10)

afferent arterioles juxtaposition renal glomerulus
(juxtaglomerular apparatus)
perfusion pressure
proteolytic enzymes
renin renin !-globulin (angiotensin)
angiotensin I angiotensin I
inactive labile decapeptide converting enzyme
angiotensin II potent vasoconstrictor
aldosterone zona glomerulosa
adrenal cortex aldosterone
renal
tubules ( 16.1)
angiotensin II
,
distal convoluted tubules (macula densa)
distal tubules
feed back renin
renin

renin

renin dependent hypertension

renin
renin

volume-dependent hypertension
5-15

1o aldosteronism 3.0 mg/
dL
RVH essential hypertension

RVH
(1,2,3,4)
1.
2.
3.
4. abdominal epigastric bruit
5.
6. 105
Screening test

1. intravenous pyelography (IVP) delayed
function
75
RVH ( 16.2)
2. captopril test captopril
(ACE inhibitor) baseline plasma
renin activity
plasma renin
test sensitivity 100% specificity
90
3. captopril renal scaning
glomerular filtration rate
(11,12)
RENOVASCULAR HYPERTENSION
16.1 Renin-angiotensin system
151
152
16.2 Intravenous pyelography (IVP)

delayed excretory function
16.3 Arteriography aorta renal

arteries proximal stenosis
4. duplex ultrasonography
1-2
(13,14,15)
5. ultrasonography parenchyma

6. magnetic resonance angiography

baseline renin catapril 25 mg

30 renin
3

RVH
Renin determination
gold standard

120 mmHg ( 16.3) 2
lateral oblique
arteriogram aorta
splenic, hepatic, celiac superior mesenteric arteries
extra-anatomic
reconstruction
spiral CT scanning
3 sensitivity 90
specificity 80 (18)

renal veins IVC
renal veins renin(16,17)
1.5 1.0
collaterals

beta blocker
renin
Arteriography
153
carbondioxide arteriography

20

(19)
, ,
,
(2)

percutaneous transluminal angioplasty (PTA)
( 16.4)
1. Percutaneous transluminal angioplasty (PTA)

Gruntzig .. 1978

atherosclerotic fibrodysplastic intima
fibrodysplastic disease

37-60
, intimal flap
(20,21)
fibromuscular dysplasia (FMD)
PTA
main artery
16.4 renovascular hypertension (RVH)
154
grafts

4
( ) (28)
hypogastric artery
6 PTFE graft ( 16.5 ....)
bilateral ostial atherosclerotic lesions PTA

14-45 1

cholesterol embolization, vessel thrombosis (22)
2. (23-27)
2.1 aortorenal bypass grafts autologous saphenous vein hypogastric artery
16.5 Aorto renal reconstruction

.
.
.
.
unilateral aortorenal bypass graft

bilateral aortorenal bypass graft
aortorenal bypass autogenous saphenous vein graft
aortic and renal reconstruction
155
2.2 thromboendarterectomy atherosclerosis ostia transverse

aortotomy
endarterectomy ( 16.6)
2.3 ex-vivo reconstruction fibromuscular
dysplasia, aneurysms
partial resection
hypothermic perfusion reconstruction
(29)
2.4 extra-anatomical renal artery revascularization

hepatic splenic artery
(30,31) ( 16.7)
2.5 nephrectomy reconstruct excretory
function

atherosclerosis
35
conservative
RVH

15-20 (32,33)
50-60
75-90
2-3
azotemia 2 mg/dL
5-7
16.6 Transaortic renal endarterectomy with patch

closure
16.7 Extra-anatomical renal revascularization

hepatic splenic arteries
156

RVH
RVH
aneurysms, emboli, arteriovenous fistula
PTA

RVH
angiotensin-converting enzyme (ACE) inhibitors calciumentry blockers RVH
RVH PTA
ex-vivo
renal reconstruction renal autotransplantation

RVH
nephrectomy
157
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21-5.
2. Chiantella V, Dean RH. Basic data related to clinical decision
making in renovascular hypertension. Ann Vasc Surg 1988;2: 92-8.
3. Berglund G, Anderson O, Wilhelmson L. Prevalence of primary and
secondary hypertension: Studies in a random population sample.
Br Med J 1976;2:554-6.
4. Ram CVS. Renovascular hypertension. Cardiol Clin 1988;6: 483508.
5. Veiball H. Percutaneous transluminal angioplasty versus surgical
reconstruction of atherosclerotic renal artery stenosis: A prospective randdomized study. J Vasc Surg 1993;18: 841-8.
6. Zierler RH, Bergelin RO, Isaacson JA, Strandness DE Jr. Natural
history atherosclerotic renal artery stenosis: A prospective study
with duplex ultrasonography. J Vasc Surg 1994;19: 200-59.
7. Stanley P, Gyepes MT, Olsen DL, Gates GF. Renovascular hypertension in Children and adolescents. Radiology 1978;129:123-31.
8. Zelenok GB. Renal and mesenteric ischemia. Prob Gen Surg 1994;11:
450-62.
9. Robaezewski DL, Dean RH. Pathophysiology of renovascular hypertension. In: Vascular Surgery: Basic science and chinical correlations. White RA, Hollier LH (eds). JB Lippincott, 1994;263-80.
10. Skoggs LT, Dorer FE, Kahn JR, et al. The biochemistry of reninangiotensin system and its role in hypertension. Am J Med
1976;60:737-748.
11. Meier GH. Captopril renal scintigraphy: A new standard for predicting outcome after renal revascularization. J Vasc Surg
1993;17:280-91.
12. Joseph V, Nally JR. Captopril renography in renal vascular disease.
In: Novick A, Scoble J, Hamilton G (eds). Renal vascular disease.
London: WB Saunders, 1996;195-205.
13. Hansen KJ, Reavis SW, Dean RH. Use of duplex scanning in renovascular hypertension. In: Technologies in Vascular Surgery. Yao
JST, Pearce WH (eds). WB Saunders, 1991;174-81.
14. Guzman RP, Zierler RE, Isaacson JA, et al. Renal atrophy and
arterial stenosis: A prospective study with duplex ultrasound. Hypertension 1994;23: 346-50.
15. Stracos TA, Parker SH, Yakers WF, et al. Segmental stenosis of the
renal artery: Pattern recognition of Tardeus and Pannus abnormalities with duplex sonography. Radiology 1992;184: 487-92.
16. Canzanello VJ, Tertor SC. Noninvasive diagnosis of renovascular
disease. Mayo Clin Proc 1994;69: 1172-84.
17. Stanley JC, Fry WJ. Surgical treatment of the renovascular hypertension. Arch Surg 1977;112:1291-7.
18. Rubin GD, Dake MD, Napel S, et al. Spiral CT of renal artery
stenosis: Comparison of three-dimensional rendoring techniques.
Radiology 1994;190: 181-9.
19. Hawkins IF, Kerns SR. Carbondioxide digital subtraction angiography. In: Cope C (edd.). Current techniques in interventional radiology. Philadelphia:Current Medicine, 1994;11.1-11.7.
20. Miller GA. Percutaneous transluminal angioplasty V.S. surgery for
renovascular hypertension. AJR 1985;144: 447-58.
21. Ramsay LF, Waller PC. Blood pressure response to percutanous
transluminal angioplasty for renovascular hypertension: An overview of published series. Br Med J 1990;30: 569-72.
22. Bergentz SE, Weibull H, Bergqvist D. Long-term patency after
reconstructive surgery and PTA for renal artery stenosis: In:
Greenhalgh RM, Hollier L (eds). The maintenance of arterial reconstructions. London: WB Saunders, 1991;384-96.
23. Stanley JC. The evolution of surgery for renovascular occlusive
disease. Cardiovasc Surg 1994;2: 195-206.
24. Hansen KJ. Comtemporary surgical management of renovascular
disease. J Vasc Surg 1992;16(3): 319-27.
25. Stanley JC, Gerwetz BL, Fry WJ. Renal: Systemic indices and renal vein renin ratio as prognostic
indications in remedial renovascular hypertension. J Surg
Res 1976;20:149-55.
26. Novick AC. Trends in surgical revascularization
for renal artery disease. JAMA 1987;257:498-506.
27. Stanley JC. Surgical interventions in pediatric
renovascular hypertension. Clin Nephrol 1992;12:167-76.
28. Dean RH, Wilson JP, Burkett, Foster JH. Saphenous vein aortorenal
bypass grafts. Ann Surg 1974;180:469-78.
29. Novick AC. Extra corporeal microvascular reconstruction and autotransplantation for branch renal artery disease. In: Novick A,
Scoble J, Hamilton G. (eds.). Renal vascular disease. London: WB
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30. Fergamy A, Kolettis P, Novick AC. The comtemporary, role of
extra-anatomic surgical renal revascularization in patients with
atheroclerotic renal artery disease. J Urol 1995;153:1798-1802.
31. Reilly JM, Rubin BG, Thompson RW, et al. Long-term effectiveness
of extra-anatomical renal artery revascularization. Surgery 1994;110:
984-96.
32. Frishmen WH. B-adrenergic blockers. Med Clin North Am
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33. Erdos EG. Angiotensin converting enzyme and the change in our
concepts through the year. Hypertension 1990;16:363-70.
158
17
FEMORO-POPLITEAL-OCCLUSIVE
DISEASE

aortoiliac occlusive disease (AIOD)
11
Intermittent claudication (IC) superficial femoral artery (SFA) Adductor canal (Hunters canal)
50-60
IC
popliteal artery atherosclerosis(1) (
17.1)
collaterals profunda femoris popliteal artery
IC 3-5
50 (1,2)
IC femoro-popliteal
occlusive disease AOID
hemodynamic rest
pain, disabling claudication gangrene
limb-threatening ischemia severe claudication
claudication

(claudication distant time)

neuromuscular disorder spinal stenosis
(3,4)
ischemic rest pain

neuritis
arthritis
gangrene
pressure area
metatarsophalangeal joint venous ulcer venous stasis neurotropic ulcer
metatarsal head blue toe syndrome
microemboli digital arteries

atherosclerotic process

femoral
(5) ABI 0.51 0.5 threatened limb loss
160
Aorta
Internal iliac
External iliac
Common femoral
Profunda femoris
Superficial femoral
Popliteal
Lateral superior
genicular
Posterior tibial
Peroneal
Anterior tibial
Popliteal
Highest genicular
Medial superior
genicular
Middle genicular
Lateral inferior
genicular
Anterior tibial
recurrent
Anterior tibial
Medial inferior
genicular
Posterior tibial
Peroneal
17.1
FEMORO-POPLITEAL-OCCLUSIVE DISEASE
trophic changes
gangrene

1. systemic factors

major organ failure

CVA femoro-popliteal occlusive disease 15-25 coronary
heart disease
(6)

MI, CHF, unstable angina, 70
2. Inflow disease AIOD femoropopliteal occlusive disease
femoropopliteal occlusive disease
ischemic rest pain disabling
claudication
(AIOD) femoropopliteal occlusive disease

3. segmental pressures plethysmography noninvasive test
segmental arterial
pressure standard pressure cuff
continous-wave doppler probe

55 pulse-volume recording amplitude 5-10
limb threatening condition
(7,8)
arterial calcification Aire pl-
161
ethysmography (pulse-volume recording)
4. Duplex scanning
iliac, femoral popliteal
invasive studies
color duplex scanning degree
saphenous
interposition graft
bypass
5. Arteriography

infra renal aorta
( 17.2) magnetic resonance arteriography (MRA)
distal arteries
17.2 Arteriogram
femoral artery
superficial femoral artery middle 1/
3 collaterals profunda femoris
popliteal artery
162
femoropliteal stenosis

5 IC 10-15
60-70
15-30(2,7)

(8,9)
1. disabling claudication
2. ischemic rest pain, gangrene

1.
femoropopliteal stenosis
atherosclerosis

(10)
IC graft
patency (11)
2. IC

collaterals
(12,13)
3. prostaglandins IC

hemorrheologic agent Pentoxifylline
IC
RBC
(14)
6-8
Pentoxifylline
rest pain, ischemic ulcer gangrene
1. Angioplasty Percutaneous transluminal

angioplasty (PTA)

iliac
3 good runoff 5-year patency rates 70
femoral popliteal
5-year patency rate 17-68 (
17.3)
PTA

2. Femoropopliteal femoro distal bypasses

limb-threatening
disabling claudication, rest pain gangrene (15)
femoro popliteal bypass
popliteal bypass femoral artery popliteal
arteries ( 17.4)
autogenous vein graft saphenous
caphalic vein polytetrafluoroethylene graft(16)
threatened limb loss femoropopliteal
bypass 5-year patency rates 75-80
limb salvage rates 85-90 limb
loss ( 17.4)
bypass

greater saphenous vein, arm veins, cephalic vein lesser saphenous vein
163
17.3 . Stenosis left common iliac artery

. left common iliac artery
. Percutaneous Transluminal Angioplasty (PTA)

superficial femoral artery
common femoral artery
. PTA superficial femoral artery
popliteal artery
164
17.4
superficial femoral artery distal arteries
(tibioperoneal)
. sequential bypasses femoropopliteal
popliteal distal bypass
. femoro distal bypass
17.1
Reversed, In-situ Nonreversed
translocated vein grafts
Grafts
femoro-popliteal femorotibial bypass saphenous vein

in-situ technique(17) Leather
saphenous vein
bypass ( 17.1) saphenous vein vulvulotome
valves tributaries vein
saphenous vein femoral artery
popliteal tibio-peroneal
arteries
( 17.5)
autogerous vein 3 year patency
rates 80-90(17)
Reversed
In-situ
vulvulotume

tunnel

No size mismatch
ischemic time
Nonreversed No size mismatch

translocated !
saphenous
vein
vasa vasorum
ischemia
Size mismatch
vulvulotome trauma
Vein graft

vasa vasorum
ischemia
vulvutome trauma
* Size mismatch

165
End-to-side anastomosis
Valve incision
Saphenous vein
Tied
Femoral artery
Distal popliteal artery
End-to-side anastomosis
saphenous vein
17.5 In Situ saphenous femoropopliteal tibial bypass grafting
. greater saphenous vein

. saphenous vein vulvulotume valves
. saphenous vein arterio venous fistula
common superficial femoral artery popliteal tibio-peroneal arteries
.

femoropopliteal-tibial aortoiliac occlusive
diseases (AIOD) collaterals
disabling claudication ischemic rest pain gangrene
inguinal ligament
AOID
PTA bypass grafting
distal bypass
In Situ saphenous vein bypass
grafting
166
1. Boyd AM. The natural course of arteriosclerosis of the lower extremities. Proc Roy Soc Med 1962;55:591-597.
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3. Goodreau JJ. Rational approach to the differentiation of vascular
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claudication syndrome produced by compression of the cauda
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risk factors in patients with peripheral vascular disease. Surgery
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1991;4:481-487.
10. Lithe IIH, Hedstrand H, Karlsson R. The Smoking habits of men
with intermittent claudication. Acta Med Scand 1975;197:473-481.
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15. Hobson RW II. Results of revascularization and amputation in
severe lower extremity ischemia: A five-year clinical experience. J
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16. Quinones-Baldrich WJ. Long-term results of infrarenal
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1991;13:189-196.
18
Buergers disease
(Thromboangitis Obliterans)
Buerger 1908(1)

presenile spontaneous
gangrene intima
50
Wessler 1960
(2)
(3,4,5) 5/100,000
(6)
Buergers Thromboangiitis
Obliterans (TAO)

(7) passive smoker

cotinine metabolite nicotin

passive smoker(8)

(9-12)
rickettsiosis, hepatitis B virus
(7,13,14)
TAO inflammatory occlusive disease
(9,12,14,15)
TAO
1. Early stage
panvasculitis
fresh thrombus thrombus
focal infiltration multinucleated giant cells, epithelioide cells leukocytes
microabscesses lymphocytes fibroblasts
media adventitia necrotizing
lesion media intima
internal elastic membrane
granulomatous reaction giant cells thrombus
TAO arteriosclerosis obliterans simple thrombosis
(16-18) disruption internal elastic lamina fibrinoid necrosis
necrotizing vasculitis
2. Subacute stage microabscess recanalization thrombus
168
3. Late stage

recanalization thrombus fibrous thickening intima fibrous tissue
media adventitia internal elastic membrane

fibrosis

rest pain

mottling rubor ( 18.1) ( 18.1)
foot claudication
18.1 TAO
Burning pain on foot and hand
Chronic ulceration of toe finger
Digital gangrene
Raynauds phenomenon
Superficial thrombophlebitis
74.8%
59.8%
53.3%
36.4%
48.6%
10.3%
107 106 1
25-40
popliteal artery
calf claudication
popliteal artery digital gangrene
Raynauds phenomenen paresthesia
2 extremities (9,15,19)
Fontaine stepwise classfication
arteriosclerosis obliterans
TAO
claudication venous filling
time 20 (20)
recurrent superficial thrombophlebitis

2-3
phlebitis
migranes pathognomonic sign TAO

98:2
(6,9)
16-18(21)
18.1 superficial femoral

TAO collaterals (cock screw)

Shionoya TAO
(9,16,17)
1.
2. 50
3. popliteal artery
4. phlebitis migranes
169
Buergers disease (Thromboangitis Obliterans)

18.2 Thromboangiitis
Obliterans Arteriosclerosis Obliterans
TAO
25-50

(,
.

superficial thrombophlelitis >40%
Raynauds phenomenon >40%
AO
55
5. arteriosclerotic factors
arteriography
arteriosclerosis
50
collagen disease scleroderma SLE
( 18.2 18.3)
atherosclerosis, vasculopathy hypercoagulability CBC, BUN, FBS

lipid profile
rheumatic disease vasculitis
erythrocyte sedimentation rate (ESR), antinuclear antibody (ANF), rheumatoid factor (RF)
hypercoagulable state protein C S, antithrombin III, lupus anticoagulants
anticardiolipin antibodies dysfibrinogenemia

18.3 Thromboangiitis
Obliterans Atherosclerosis
Connective tissue disease/vasculitis

Systemic Lupus Erythematosus
Rheumatoid arthritis
Scleroderma
Polyarteritis nodosa
Antiphospholipid antibody syndrome
Giat cell or Takayasus arteritis
Leukocytoclastic vasculitis
Miscellaneous
Idiopathic arterial thrombosis (i.e.,cancer, infection,
ulcerative colitis, congestive heart failure)
Blood dyscrasia (polycythemia vera)
Ergotamine abuse
Occupational hazards (vibratory tools, hypothenar
hammer syndrome)
Calciphylaxis
Thrombosis of aneurysms.
ABI, ankle toe pressure, plethysmography, digital artery flow velocity, thallium-201 perfusion
scan arteriography

skip
area
collaterals
free root cockscrew appearance(22,23) ( 18.2)
Clinical course

2 (23)
1. continuous progression
2. skip progression
170
18.4
1.
2. locial ischemic ulceration
2.1
2.1.1
2.1.2

2.1.3
2.2 calcium channel blocker nifedipine, nicardipin

pentoxifyllin
2.3 Iloprost
2.4 sympathectomy
3. cellulitis superficial phlebitis
NSAIDS
4. control ischemic rest pain
pain ischemic ulcer
18.2 Superficial thrombophlebitis
TAO ischemic ulcer
clinical course TAO 1-2
claudication
iliac secondary thrombosis
60
femoropopliteal artery 32
aortoiliac 8(9)
brachial(25) TAO
mesenteric renal(18)
( 18.4)
TAO

25 25
60

collaterals
thrombus
prostaglandin prostagladin E, (PGE1)

72 (26)
TAO

epidural anesthesia, prostaglandin infusion,
hyperbaric oxygenation
171
Buergers disease (Thromboangitis Obliterans)

18.5
TAO
Amputation
sympathectomy
direct reconstruction
107
107
88
.. ..
( 18.5)
1.

topical

2. dry gangrene
demarcation

TAO

(major amputation)
3. sympathectomy TAO
rest
pain
(9,17)
sympathectomy

(ABI<0.3)
4. arterial reconstruction

distal run-off
TAO
reconstruct bypass
bypass saphenous vein graft

migratory phlebitis

revascularization TAO
10-17.3 (9-11)

distal run-off
saphenous vein

20
20 (9,11)
brachial artery 10 (25)
60
172
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Buergers disease: its incidence and primary lesions. Br J Surg
1979;66:124.
26. Fiessinger JN, Shafer M. Trial of Iloprost vs Aspirin treatment for
critical limb ischemia of thromboangiitis obliterans. Lancet
1990;335:555-557.
19
TAKAYASUS ARTERITIS
arteritis
transmural necrosis
vasculitis
necrosis occlusions
(1)
hypersensitivity reaction ( 19.1)
Takayasus arteritis
aorta
35
10-30 pulseless
disease, nonspecific aortoarteritis, arteritis in young
women, atypical aortic coarctation middle aorta syndrome(2-5)
(6-9)
(10,11)

(12)
aortic arch
abdominal aorta

pulmonary artery
pulmonary hypertension
(2-5,12)
Takayasus disease
4 (12,13) ( 19.1)
1 aortic arch
9
2 descending aorta, abdominal
aorta
11
3 aortic arch
abdominal aorta 65
4 aorta
pulmonary artery 15
II
III
IV
19.1 Takayasus arteritis
174
patchy granulomatous inflammation adventitia, vasa vasorum media
lymphocytes, histiocytes multinucleated giant cells

panarteristis (12)
reactive hyperplasia intima
adventitia media
sclerosis calcification aneurysm (4,512)
acute phase

(2)

CVA claudication
syncope
dementia coarctation of the aorta
(3,4,14)
pulmonary artery

bruit systolic murmur
retinal arteriovenous anastomosis, visual field deficits
(5)
CBC 50
normochromic normocytic anemia
(LVH, LAE) erythrocyte sedimentation rate (ESR) marker

(5,5)
arteriography
aor-
tic arch pulmonary artery, abdominal aorta

(15,16)

(17)
acute phase NSAIDs
steroid steroid prednisolone
40-60
3 46 2-4
monitor ESR
steroid cytotoxic
drugs cyclophosphamide cyclosporin

Tasayasu
19.1 Nonatherosclerotic vascular conditions
Inflammatory conditions
Arteritis
Takayasus arteritis
Giant cell arteritis
Polyarteritis nodosa
Hypersensitivity arteritis
Kawasakis disease
Bechets disease
Buergers disease
Noninflammatory conditions
Fibromuscular conditions
Inherited dysplasia
Marfan syndrome
Congenital and development disease
Abdominal aortic coarctation
Persistent sciatic artery
Adventitial cystic disease
Popliteal artery entrapment
175
TAKAYASUS ARTERITIS
coarctation of the
aorta
endarterectomy

bypass
acute phase
prednisolone
(18-22)
bypass Takayasus disease

6-year survival
rate 98
45 (23,24)
1. Conn DL, Hunder GG. Necrotizing vasculitis. In: Kelly WN, Hanis
ED, Ruddy S, Sledge CB, eds. Textbook of Rheumatoly. 3rd ed.
Philadelphia: WB Saunders, 1989:1137.
2. Lupi-Herrera E, Sanches-Torres G, Marcustiamer J, et al. Takayasus
arteritis: Clinical study of 107 cases. Am Heart J 1997;93:94-103.
3. Hall S, Buchbinder R. Takayasus arteritis. Rheum Dis Clin North
Am 1990;16:411.
4. Sekiguchi M, Suzuki J. An overview of Takayasus arteritis. Heart
Vessels 1992(Suppl);7:6-10.
5. Deyu Z, Digun F, Lisheng L. Takayasus arteritis in China:A report
of 530 cases. Heart Vessels 1992(Suppl);7:32-36.
6. Deyu Z, Digun F, Ligheng L. Takayasus arteritis in China:A report
of 530 cases. Heart Vessels 1992(Suppl);7:32-36.
7. Koide K. Takayasus arteritis in Japan. Heart Vessels 1992
(Suppl);7:48-52.
8. Piyachon C, Suwanwela N. Takayasus arteritis in Thailand. Heart
9. Rosenthal T, Morag B, Itzchak Y. Takayasus arteritis in Israel. Heart
10. Halls, Ban W, Lie JE, et al. Takayasus arteritis: A study of 32 North
American patients. Medicine 1985;64:89-99.
11. Hotchi M. Pathological studies on Takayasus arteritis. Heart Vessel
1992 (Suppl);7:11-17.
12. Arend WP. The American College of Rheumatology 1990 criteria
for the classification of Takayasus arteritis Rheum 1990;33:1129.
13. Takayasu U. A case with unusual changes of the central vessels of

the retina. Acta Soc Ophthalmol Jap 1908;12:554.
14. Park YB, Hong SK, Choi KT, et al. Takayasus arteritis in Korea:
Clinical and angiographic features. Heart Vessels 1992(Suppl);7:5559.
15. Cho YD, Lee KT. Angiographic characteristics of Takayasus arteritis. Heart Vessels 1992(Suppl);7:97-101.
16. Ito I. Medical treatment of Takayasus arteritis. Heart Vessels 1992
(Suppl);7:133-137.
17. Weaver FA, Yellin AE. Surgical treatment of Takayasus arteritis.
Heart Vessels 1992(Suppl);7:154-158.
18. Tada Y, Sato O, Oshima A, et al. Surgical treatment of Takayasus
arteritis. Heart Vessels 1992(Suppl);7:159-167.
19. Robbs JV, Human RR, Rajaruthnam P. Operative treatment of nonspecific aortoarteritis (Takayasus arteritis). J Vasc Surg 1986;3:605.
20. Scott D. Surgical repair of visceral artery occlusions in Takayasus
disease. J Vasc Surg 1986;3:904.
21. Weaver FA. Surgical porcedures in the management of Takayasus
arteritis. J Vasc Surg 1990;12:429.
22. Ishikawa K. Survival and mortality after diagnosis of occlusive
thromboarthrophasty (Takayasus disease) Am J Cardiol 1981;47:10261032.
23. Morwaki R, Numano F. Takayasus arteritis: follow up studies for 20
years. Heart Vessels 1992(Suppl);7:138-145.
176
20
ACUTE ARTERIAL
OCCLUSION
Thomas J. Fogarty balloon catheter
1963 arterial emboli
thrombi
(1)

survival of limb acute limb
ischemia ,
, peripheral vascular disease
acute arterial occlusion (2)

1. Arterial embolism

1.1 cardiac causes
90 atherosclerotic heart disease atrial fibrillation

2-3

cardiomyopathy, left ventricular aneurysm, , endocarditis
atrial myxoma
1.2 atheroembolization
atherosclerotic plaque
microscopic stenosis thrombosis
hypotension, dehydration,
, polycythemia, hyperviscosity hypercoagulable states
5-8
thrombosis

collaterals
2. In-situ arterial thrombosis arteriosclerotic stenosis dissecting aneurysm ( 20.1)
3. vasculitis,
, , graft occlusion
cervical rib syndrome

cardiac emboli

superficial femoral artery (SFA) common
femoral artery (CFA)
bifurcation
visceral arteries(3,4,5) ( 20.2)
178
20.1 . mural thrombus infrarenal abdominal aortic aneurysm
. mural thrombus AAA 20.1 . left popliteal artery
aorto-iliac ulcerated plaque

aneurysms popliteal tibioperoneal arteries microemboli
digital arteries blue toe syndrome(6,7)
hypotension,
dehydration, polycythemia, hyperviscosity, hypercoagulable state thrombosis

collaterals (8)

sympathetic tone hypoxia
secondary thrombus

collaterals
permeability
capillary system interstitial edema erythrocyte sludging intravascular coagulation hemolysis venous thrombosis
hypercoagulability embolism
vasa vasorum degeneration of amyelinic fibrous type C

motor nervous
system degeneration 6 (9)

anaerobic metabolism
anoxia acid radicals
179
ACUTE ARTERIAL OCCLUSION
Upper Extremity 14%
Visceral 7%
Aortoiliac 22%
Femoral 36%
Popliteal 15%
Other 6%
cell membrance permeability

cutaneous tissue
24
(8,10,11,12,13)
1.
2. percentage of lumen obstruction
3.
4. state of collateral circulation
5. degree of thrombus propagation
6. cardiac output
7. blood viscosity
8.
20.2 cardiac emboli
74
.. 2533-2535

metabolism
revascularize reperfusion syndrome
systemic circulation

degree of tissue necrosis ,
respiratory distress syndrome multiple organ failure(9,13,14)
812 vasospasm
(mottling) poor capillary filling collapsed
180
20.1 condition ischemic lower limb
1. early ischemia paresthesia, pallor

pulselessness limb viable
2. advanced ischemia paralysis rigor
non-viable limb
(poikilothermia) (
20.3) 6 Ps
pain, pallor, paresthesia, pulselessness, paralysis
poikilothermia
1 joint
( 20.2)
advanced ischemia
ankle dorsiflex
complete foot paralysis
revascularization motor function
muscle rigor nonviable extremity
( 20.1)
arterial thrombosis
embolism claudication
embolism
trophic skin changes, ,
(15,16)

embolization in-situ thrombosis

5-20 (15%)
Intermittent
claudication

1.

thoracic aortic disease polycythemia
myoglobinuria
creatinine phosphokinase
EKG
2-dimensional echocardiography ejection
fraction thrombus
ASD ultrasound AAA
popliteal artery aneurysm (
20.2)
2. Arteriography advanced ischemia embolism
embolectomy
embolism thrombosis arteriography

sharp, convex-appearing cutoff ( 20.5) thrombosis
atherosclerosis
collaterals irregular
tapering ( 20.6)
3. Duplex scanning
noninvasive
distal outflow tract
venous thrombosis
20.2
, PT/PTT
Electrolytes, BUN, Creatinine
myoglobinuria
CPK isoenzymes
EKG
Two-dimensional echocardiogram
181
20.3

blebs, mottling, superficial
skin necrosis
If nutritional changes above knee

then occlusion is at aortic bifurcation
Common femoral occlusion
Superficial femoral occlusion minimal
nutritional changes if distal bed open
Popliteal artery occlusion
Distal block to popliteal bifurcation
20.4

1
182
20.5
20.6 thrombosis
arteriography
sharp, convex-appearing cutt-off
arteriography
atherosclerosis collaterals
irregular tapering
saphenous bypass duplex

scanning

partial thromboplastin (PTT)

1.5-2
inflammatory factors distal clot
propragation
collaterals anticoagulants

collaleral flow
ischemic demarcation

viable limb anticoagulants

elective (4,5,10,11,15,16) ( 20.3)
limb-threatening

distal clot propragation

5,000
1,000
20.3
1. propragation of clotting loading dose heparin
2.
, doppler US, EKG arteriography
arterial embolism
acute thrombosis
atherosclerotic artery
atherosclerotic aneurysm
dissecting aneurysm
phlegmasia cerulea dolens
3. dehydration,
delay operation
4. vasodilators, sympathetic blockers
5.

repurfusion embolectomy, arterial repair, venous thrombectomy
proof distal patency doppler
US intraoperative arteriography
4-6
pain, paralysis paresthesia limb viability

anticoagulants
thrombosis limb
viable anticoagulants collaterals

revascularization elective (17,18)
8

underlying diseases
COPD, CHF revascularization ischemic waste products central circulation

183
reperfusion syndrome high full dose
arteriography

blanching viable
blanding non-viable

dose
5 heparininduced thrombocytopenia dose
3-4 dose therapeutic level

7 oral anticoagulant 7 anticoagulant
viable partial necrotic
amputate, revascularize anticoagulant
anticoagulant

(19) ischemic viable limbs

thromboembolectomy revascularization
adequate dose anticoagulant
thrombus propragation
anticoagulant amputation
48 viable anticoagulant dose collaterals arteriography revascularize

Warfarin (Coumadin)

184
embolectomy
underlying disease

8
embolectomy local regional
anesthesia(1)
Fogerty balloon tip catheter
proximal distal control

arteriotomy

back bleeding
distal pulsation clot clot
( 20.7) clot
arteriography(20)
20.7
Fogarty balloon tip catheter

Aortic saddle, iliac femoral embolectomies

femoral artery
vertical control common, superficial
profunda femoral dissection aortic saddle emboli
bilateral femoral dissection control femoral
arteries 2 thrombus
venous thrombosis
venous thrombectomy
thrombosis atherosclerotic artery longitudinal
transverse embolectomy
bypass
aortoiliac thromboembolectomy Fogarty
cath 4 5F
catheter
clot

false aneurysm arteriovenous fistula, dissection
intimal flap(21,22) diluted heparinized saline
arteriotomy arterial pressure
intra operative arteriography
Femoral embolectomy Fogarty catheter 4F

profunda femoris 3F
20-25 clot
superficial femoral artery
(23)
Popliteal emboli 15 embolectomy
transfemoral Fogarty catheter 3F(24)
clot tibioperoneal artery
medial approach distal popliteal
tibioperoneal arteries embolectomy
Fogarty catheter 2F(25)
angioscopy thrombo embolectomy clot
angioscope 2.8

angioscopy thromboembolectomy (26)
185
1. clot
2. inflate
3. clot blind embolectomy

4. catheter

5. angiogram x-ray
6. popliteal
tibioperoneal arteries
24 ICU

rethrombosis recurrent emboli

revascularization 20.4
Thrombosis
thrombosis
emboli embolectomy anticoagulant
(11,16,17,27,28,29) thrombosis anticoagulant
conservative
revascularization
thrombosis censervative management arteriogram
revascularize
20.4 Revascularization
Thrombosis
Recurrent emboli
Pulmonary emboli
Microembolic acute respiratory distress syndrome
myocardial infarction, arrhytmias

Mesenteric infarction
Postoperative Anticoagulation

72 Coumadin (Warfarin) (30)
melena, hematuria,
ecchymosis,
monitor , platelet count partial thromboplastin time (PTT)

Protamine

, CVA, pulmonary infarction
recurrent emboli thrombi (31)
Fasciotomy
revascularization

fasciotomy
muscle compartments
(32) fasciotomy
necrotic muscle
fasciotomy
media fasciotomy compartments
venous obstruction fasciotomy

necrotic muscle
Fibrinolytic Therapy
advanced ischemia Fibrinolytic therapy

12-24
6-8 subacute ischemia thrombi emboli
Fibrinolytic therapy
clot
( 20.5)
plasminogen
186
20.5 Fibrinolytic Therapy

Intracranial hemorrhage
Arterial site hematoma
Distal embolization
lysis
pseudointima Dacron graft
Retroperitoneal hemorrhage
activator
thrombus (33,34,35)
Streptokinase (SK) nonenzymatic protein
group C B-hemolytic streptococci plasminogen active enzymatic complex
plasminogen plasmin
5,000-10,000 IU/h 12-48
arteriography thrombus
SK
antigen-antibody interaction
Streptokinase streptococcal antibodies
Urokinase human renal cells
tissue culture antigenic trypsin
like protease plasminogen plasmin
20,000 IU/h SK
Fibrinolytic therapy fresh thrombus

organized thrombus
clot propation SK clot
clot
collaterals fibrinolytic agent
clot
systemic fibrionolysis
monitor Thrombin time, platelet counts,
fibrin split products
anticoagulant

emboli thrombi

clot propagation emboli embolectomy rigor
paralysis
revascularize embolectomy
thrombosis
arteriography
acute thrombosis
anticoagulant
elective thrombosis
limb threatening condition
revascularize bypass operation
reperfusion
syndrome compartment syndrome
severity of ischemia,
, ,
fibrinolytic therapy cardiac
emboli anticoagulants
187
1. Fogarty TJ, Cranley JJ, Krause RJ, et al. A method of extraction of

arterial emboli and thrombi. Surg Gynecol Obstet 1963;116:241250.
2. Haimovici M. Acute atherosclerotic thrombosis. In: Vascular Emergencies. New York: Appleton-Century-Croft 1982;213-223.
3. Elliot JP, Hageman JH, Szilagyi E, et al. Arterial embolization:
Problems of source, multiplicity, recurrence, and delayed treatment.
Surgery 1980;88:833-845.
4. Eglund R, Magee HR. Peripheral arterial embolism: 1961-1985.
Aust N2 J Surg 1987;57:27.
5. Baxter-Smith D, Ashtib F, Stanley G. Peripheral arterial embolism:
a 20 year review. J Cardiovasc Surg 1988;29:453.
6. Kempczinski RF. Lower extremity arterial embolus from ulcerating
atherosclerotic plaques. JAMA 1979;241:807.
7. Lord JW Jr, Rossi G, Daliana M, et al. Unsuspected abdominal
aortic aneurysm as the cause of peripheral arterial occlusive disease. Ann Surg 1973;177:767.
8. Jivegerd L, Holm J, Schersten T. Acute limb ischemia due to
arterial embolism or thrombosis: Influence of limb ischemia versus
pre-existing cardiac disease on postoperative mortality rate. J
Cardiovasc Surg 1988;29:32.
9. Haimovici H. Metabolic complications of acute arterial occlusions.
J Cardiovasc Surg 1979;20:349-357.
10. Lusby RJ, Wylie EJ. Acute lower limb ischemia: Pathogenesis and
management. World J Surg 1983;7:340.
11. Tawes RL, Harris EJ, Brown WH, et al. Arterial thromboembolism:
A 20-year perspective. Arch Surg 1985;120:595.
12. Jivegard L. Selective conservation and routine early operation in
acute limb ischemia. Br J Surg 1987;74:798-801.
13. Caruana JA, Cutierrez IZ, Anderson MN, et al. Factors that affect
the outcome of peripheral arterial embolization. Arch Surg
1981;116:423-425.
14. Haimovici H. Muscular, renal and metabolic complications of acute
arterial occlusions: Myonephropathic-metabolic syndrome. Surgery
1979;85:461-468.
15. Blaisdell F, Steele M, Allen R. Management of acute lower extremity arterial ischemia due to embolism and thrombosis. Surgery
1978;84:822-831.
16. Dale A. Differential management of acute peripheral arterial ischemia. J Vasc Surg 1984;1:269-276.
17. Mills JL, Porter JM. Basic data related to clinical decision-making
in acute lime ischemia. Ann Vasc Surg 1991;5:96-98.
18. Yeager RA, Moneta GL, Taylor LM, et al. Surgical management of
severe acute lower extremity ischemia. J Vasc Surg 1992;15:38539.
19. Blaisdell FW, Stells M, Allen RE. Management of acute lower

extremity arterial ischemia due to embolism and thrombosis. Surgery 1978;84:822-829.
20. Mavor GE, Walker MG, Dhall DP. Routine operative arteriography
in arterial embolectomy. Br J Surg 1972;59:482-484.
21. Schweitzer DL, Aguam AS, Wilder JR. Complications encountered
during arterial embolectomy with the Fogarty balloon catheter. Vasc
Surg 1976;10:144-156.
22. Foster JH, Carter JW, Graham CP, et al. Arterial injuries secondary
to the use of the Fogarty catheter. Ann Surg 1970;171:971-978.
23. Short D, Vaughn GD III, Jachimczyk J, et al. The anatomic basis
for the occasional failure of transfemoral balloon catheter thromboembolectomy. Ann Surg 1979;190:555.
24. Gupta SK, Samson RH, Veith FJ. Embolectomy of the distal part of
the popliteal artery. Surg Gynecol Obstet 1981;153:255.
25. Wyffells PL, DeBord JR. Increased limb salvage. Distal tibial/
peroneal artery thrombectomy embolectomy in acute lower extremity ischemia. Am Surg 1990;56:468-475.
26. White GH, White RA, Kopchok GE, et al. Angioscopic thromboembolectomy: Preliminary observations with a recent technique. J
Vasc Surg 1988;7:318-325.
27. Cambria RP, Abbott WM. Acute arterial thrombosis of the lower
extremity. Its natural history contrasted with arterial embolism.
Arch Surg 1984;119: 784-787.
28. McPhail NV, Fratesi SJ, Barber GG, et al. Management of acute
thromboembolic limb ischemia. Surgery 1983;93:381-385.
29. Field T, Littooy FN, Baker WH. Immediate and long term outcome
of acute arterial occlusion of the extremities. Arch Surg
1982;117:1156-1160.
30. Holm J, Schersten T. Anticoagulant treatment during and after
embolectomy. Acta Chir Scand 1972;138:683.
31. Tawes RL, Beare JP, Scribner RG, et al. Value of postoperative
heparin therapy in peripheral arterial thromboembolism. Am J
Surg 1983;146:213.
32. Patman RD, Thompson JE. Fasciotomy in peripheral vascular surgery. Arch Surg 1970;101:663.
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Obstet 1983;156:148.
34. Hargrove WC, Barker CF, Bergowitz HD, et al. Treatment of acute
peripheral arterial and graft thrombosis with low-dose streptokinase. Surgery 1982;92:981.
35. Marder VJ, Sherry S. Thrombolytic therapy: Current status. NEngl
J Med 1988;318:1585.
188
21
INFECTED ANEURYSMS
.. 1885 Sir William Osler
bacterial endocarditis fungus vegetations

Mycotic aneurysms(1)

(2,3)
syphylitic aneurysms arterial infection
bacterial
endocarditis
atherosclerotic aneurysmal
arterial lesions mycotic aneurysm(4,5)
1.
2.
aneurysm
3.
4.
( 21.1)
1. classic mycotic organisms

micro macroemboli

2. extravascular osteomyelitis, pneumonia, abscesses
bacteremia local spread
spinal osteomyelitis

aneurysm
3. direct inocculation

atherosclerotic intima ulcerated
plaque, necrotic cellular debris thrombus media
mural thrombus aneurysms
Salmonella, Staphylococcus
Streptococcus Candida Aspergillus(4,6)
190
21.1 Classification of vascular infections

Source of Infection
Intrinsic endocarditis or other intravascular
infection
Extrinsic osteomyelitis, pneumonia, or other
infection by local spread or bacteremia
Inoculation inadvertent during medical procedures,
unhygienic injections, infecting drug use
Affected Vessel
Normal resistant except in high virulence or large
inoccula
Atherosclerotic susceptible, especially to Salmonella
and Staphylococcus
Aneurysmal many more culture positive than
infections
Causative Microorganism
Salmonella - most common, 65% involve aorta
Staphylococcus - next most common
Streptococcus - seen especially with endocarditis
Other unusual organisms - as seen in unhygienic
injections, IV drug abuse and in immune deficiency
arterial infections infected

aneurysms immune suppressed hosts HIV,

hemodynamic monitoring arteriography(7-12)
infected aneurysms
infected aneurysms
( 21.2)
1. mycotic aneurysms septic arterial
emboli
2. microbial arteritis aneurysms
3. aneurysms
4. infected false aneurysm trauma
spontaneous aortoenteric fistula

(4,13,14)
MYCOTIC ANEURYSMS

atherosclerosis embolization
direct extension septic valvular vegetation
infective endocarditis(1,4) mycotic
21.2 Infected Aneurysms

Mycotic Aneurysm
Microbial Arteritis
Infected Existing
Aneurysm
Post-traumatic
Infected
Endocarditis
Bacteremia
Bacteria
()

30-50
Aorta
Visceral
Intracranial
50
-Infrarenal
Aorta
25%
50
Atherosclerotic
Aortoiliac
Intimal defects
Salmonella

75%

30

-Femoral
-Carotid
Staphylococcus

90%
Staphylococcus
aureus
5%
INFECTED ANEURYSMS
aneurysms arterial infection (3)

.. 1923 Stengel Wolferth 87
mycotic aneurysms endocardial infection
pulmonary infection osteomyelitis(3) 13 endocarditis
ruptured mycotic aneurysms

bacterial endocarditis mycotic aneurysms
bacterial endocarditis
septic arterial complications
.. 1967 10 16 infected aneurysms
bacterial endocarditis(15) 25 mycotic aneurysms 9 bacterial endocarditis 7 9 aneurysms

AIDS infected aneurysms (16,17)
mycotic aneurysms
bacterial endocarditis
ascending
aorta(18,19) emboli
vasa vasorum
vasa vasorum
intramural abscess intima (20-22)
Infected emboli thrombosis vasa vasorum

aneurysm(23) aorta, visceral peripheral arteries
histology
aneurysm infected aneurysm
mycotic aneurysm
mycotic aneurysm
intima internal elastic lamina
periarteritis mesoarteritis
plasma cells lymphocytes
vasa vasorum
191
MICROBIAL ARTERITIS WITH ANEURYSM

microbial arteritis 14 infected aneurysms
(3) bacterial endocarditis
microbial artertis
mycotic aneurysms(25)
atherosclerosis

intima
atherosclerotic arteries
intima blood-borne bacterial
suppuration, localized perforation
false aneurysm ( 21.1) aorta
microbial arteritis (13,26,27)
microbial arteritis
21.1 arteriography Staphylococcus aureus microbial arteritis with aneurysm saccular aneurysm right renal artery
192
Salmonella, Staphylococcus, Escherichia coli Bacteroides fragilis(4,28,29)

25 anaerobic bacteria
Salmonella diseased
aorta species S. choleraesuis S.
typhimurium 62(29)
INFECTION OF PREEXISTING ANEURYSMS

atherosclerotic aneurysms
3.4(5) Ernst AAA
15(30) ruptured
38 abdominal aorta
thoracic
aorta(4,31) ( 21.2)
59
35 Staphylococcus ( 41)(32)
81 19
S. epidermidis ( 53)(30)
POST-TRAUMATIC INFECTED FALSE

ANEURYSMS
infected aneurysms

( 21.3)

false aneurysm(33) femoral external iliac
carotid(34,35)

arteriography percutaneous angioplasty monitoring
procedures post-traumatic infected
false aneurysm (12,36)
S. aureus (
(25)
30) 48 methicillin resistant
33 S. aureus, E. coli,
S. faecalis, Pseudomonas aeruginosa (34)
21.2 CT scan abdomen salmonella infection preexisting

small AAA fluid wall aneurysm
193
INFECTED ANEURYSMS
21.3 . arteriograms infected false aneurysm superficial femoral artery

. arteriograms infected false aneurysm right external ilialc artery
collateral femoral arteries

infected aneurysms
, , leukocytosis,
,
atherosclerosis(5,20) infected aortic aneurysm

( 40 )
, erosion lumbar vertebrae,
uncalcified aneurysm aneurysm
sepsis(32,37) ruptured aneurysm(38)
infected aneurysms

sepsis(38)

gangrene distal embolization(10,39,40)
infected aneurysms

sepsis

infected
aneurysms leukocytosis erythrocyte sedimentation rate (ESR) (28,32)
194
50(7)
infected aneurysms
,
thrombus aerobic anaerobic
infected aneurysms 69
92
50 (32)
aortic aneurysms
vertebral body erosion calcification
infected aneurysm

CT scan digital subtraction angiography (DSA)
sonography aneurysm
infected aneurysm(41) sonography
infected femoral artery false
aneurysm ( 21.4) digital subtraction angiography
conventional angiography(42)
21.3 CT Findings of Infected Aneurysms

Saccular aneurysm
Irregular aneurysm lumen
Absence of calcification
Gas within aortic wall
Perianeurysmal gas
Perianeuryamal fluid
Encasing or contiguous mass
Associated paraaortic or psoas abscess
Vertebral osteomyetitis
angiography conventional angiography DSA infected aneurysms

(43)
1. saccular aneurysm
2. multilobulated aneurysm
3. aneurysm narrow neck
contrast-enhanced CT scan ( 21.3) Magnetic resonance imaging (MRI) aneurysm
leakage rupture
aneurysm indium111-labeled white blood cell scanning.(44)
21.4 ultrasonography false

aneurysm common femoral artery
infected aneurysm

(45)
Salmonella
ruptured infected
aneurysm
(34)

1. ruptured leakage aneurysms
2.
, thrombus
anaerobic, aerobic fungus
195
INFECTED ANEURYSMS
3.

4.

5.

6. arterial reconstruction
autologous
vessels

arterial reconstruction
aorta infected
aortic prostheses infected aneurysm
arterial reconstruction axillobifemoral bypass ( 21.5) in situ interposition aortic graft
(32,46)
graft
(47)
gross sepsis infected aneurysm
interposition grafting aortic
arch, thoracic aorta suprarenal abdominal aorta.(25,31,45)
femoral artery arterial excision arterial reconstruction
( 21.6)
infected aneurysm
obturator bypass interposition grafting
(7,11,48)

autogenous vein
infected femoral false aneurysm aneurysm
arterial reconstruction collaterals
(11,48,49,50)
(49,50)
Closed aortic stump
Axillobifemoral graft
21.5 axillobifemoral bypass infected abdominal aortic aneurysm
196
21.6 reconstruct femoral artery

. obturator bypass
. lateral femoral bypass
infected aneurysm
aneurysm condition

infected aneurysms
mycotic aneurysm 25 microbial arteritis 75 infected preexisting aneurysm
75 post-traumatic infected false aneurysm
10(4)
infected femoral artery false
aneurysm 11-25(7,48,49,50)
revascularization.
INFECTED ANEURYSMS
197
1. Osler W. The Gustanian Lectures on malignant endocarditis. Br

Med J 1885;1 467-471.
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1909;63:1808-1814.
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Probl Surg 1978;15:5.
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brachial artery: A complication of retrograde catheterization. JAMA
1974;228: 1574-1581.
9. Gouny P, Valverde, A, Vincent D. Human immunodeficiency virus
and infected aneurysm of the abdominal aorta: Report of three
cases. Ann Vasc Surg 1992;6: 239-246.
10. Kyriakides GK, Simmons RL, Najarian JS. Mycotic aneurysms in
transplant patients. Arch Surg 1976;111: 472-481.
11. Padberg F, Hobson RII, Lee B, et al. Femoral pseudoaneurysm from
drug of abuse: Ligation or reconstruction? J Vasc Surg 1992;15:
642-652.
12. Soderstrom CA, Wasserman DJ, Ransom KT, et al. Infected false
femoral artery aneurysms secondary to monitoring catheters. J
Cardiovasc Surg 1983;24: 63-70.
13. Patel S, Johnston KW. Classification and management of mycotic
aneurysms. Surg Gynecol Obstet 1977;144: 691-702.
14. Mcnamara MF, Roberts AB, Bakshi KR. Gram-negative bacterial
infection of aortic aneurysms. J Cardiovasc Surg 1987;24:453-462.
15. Perdue GDm, Smith RB III. Surgical treatment of mycotic aneurysms. South Med J 1967;60: 848-852.
16. Dean RH, Meacham PW, Weaver FA, et al. Mycotic embolism and
embolomycotic aneurysms: Neglected lessons of the past. Ann
Surg 1986;204: 300-311.
17. Dupont J, Bonavita JA, Digiovanni RJ, et al. Acquired immunodeficiency syndrome and mycotic abdominal aortic aneurysms: A new
challenge? Report of a case. J Vasc Surg 1989;10: 254-262.
18. Wang Y, Chester E, Korns ME, edwards JE. Mycotic aneurysms of
left ventricle and ascending aorta. Minn Med 1968;51: 395-401.
19. Thompson TR, Tilleli J, Johnson DE, et al. Umbilical artery catheteriztion complicated by mycotic aneurysms in neonates. Adv Pediatr
1980;27: 275-286.
20. Benette DE. Primary mycotic aneurysms of the aorta. Arch Surg
1967;94: 758-763.
21. Smith G, Hutchinson HE. Lymph borne infection and aneurysm
formation. Surg Gynecol Obstet 1957;104:722-731.
22. Buxton RW, Holderfer WF. Primary mycotic aneurysms. Am Surg
1963;29: 86323. McCrae J. A case of multiple mycotic aneurysms of the first part
of the aorta. J Pathol Bacteriol 1905;10: 373-382.
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determinants of survival in patients with mycotic aneurysm. J
Vasc Surg 1984;1:541-549.
25. Bennett DE, Cherry JK. Bacterial infection of aortic aneurysm: A
clinicopathologic study. An J Surg 1967;113: 321-332.
26. Parkhurst GF, Decker JP. Bacterial aortitis and mycotic aneurysm
of the aorta. Am J Pathol 1955;31:821-830.
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aortoiliac aneurysms. Arch Surg 1991;126: 873-882.
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29. Ernst CB, Campbell C Jr, Daugherty ME, et al. Incidence and
significance of intra-operative bacterial cultures durign abdominal
aortic aneurysmectomy. Ann Surg 1977;185: 626-635.
30. Triratvorakul P, Sriphojanart S, Sathapatayavongs B. Abdominal
aortic aneurysms infected with salmonella: Problems of treatment.
J Vasc Surg 1990;12: 16-24.
31. Jarrett F, Darling RC, Mundth ED, et al. Experience with infected
aneurysms of the abdominal aorta. Arch Surg 1975;10:1281-1290.
32. Huebl HC, Read RC. Aneurysmal abscess. Minn Med 1966;49:1118.
33. Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm: New
concepts in surgery. Arch Surg 1983;118:577-584.
34. Ledgerwood AM, Lucas CE. Mycotic aneurysm of the carotid artery. Arch Surg 1974;109: 496-503.
35. Baker WH, Moran JM, Dormer DB. Infected aortic aneurysm following arteriography. J Cardiovasc Surg 1979;20: 313-319.
36. Vozelgang RL, Sohaey R. Infected aortic aneurysms: CT appearance. J Comput Assist Tomogr 1988;12(1): 109-118.
37. Mundth ED, Darling RC, Alvarodo RH, et al. Surgical management
of mycotic aneurysms and the complications of infections. in vascular reconstructive surgery. Am J Surg 1980;191: 47-56.
38. Mendelowitz DS, Ramstedt R, Yao JST, et al. Abdominal aortic
salmonellosis. Surgery 1979;85: 514-521.
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of abdominal aortic aneurysms. Ann Surg 1983;197: 157-164.
198
40. Reddy DJ, Smith RF, Elliott JP Jr, et al. Infected femoral artery
false aneurysms in drug addicts: Evolution of selective vascular
reconstruction. J Vasc Surg 1986;3: 718-726.
41. Shetty PC, Krasicky GA, Sharma RP, et al. Mycotic aneurysms in
intravenous drug abusers: The utility of intravenous digital subtraction angiography. Radiology 1985;155: 319-326.
42. Weintraub RA, Abrams HL. Mycotic aneurysm. Am J Roentgenal
1968;102:354-361.
43. Brunner MC, Mitchell RS, Baldwin JC, et al. Prosthetic graft infection: Limitations of indium white blood cell scanning. J Vasc Surg
1986;3: 42-51.
44. Chan FY, Crawford ES, Coselli JS, et al. In situ prosthetic graft
replacement for mycotic aneurysms of the aorta. Ann Thorac Surg
1989;47: 193-202.
45. Taylor LM Jr, Deitz DM, McConnell DB, Porter JM. Treatment of
infected abdominal aneurysms by extraanatomical bypass, aneurysm excision and drainage. Am J Surg 1988;155: 655-664.
46. Ewart JM, Burke ML, Bunt TZ. Spontaneous abdominal aortic
infections: Essentials of diagnosis and management. Am Surg
1983;49:37.
47. Reddy DJ, Smith RF, Elliott JP jr, et al. Infected femoral artery false
aneurysms in drug addicts: Evolution of selective vascular reconstruction. J Vasc Surg 1986;3:718-724.
48. Feldman AJ, Berguer R. Management of an infected aneurysm of
the groin secondary to drug abuse. Surg Gynecol Obstet 1983;157:
519-528.
concepts in surgery. Arch Surg 1983;118: 577-585.
22
THE DIABETIC FOOT

(1)
50 Type II (Insulin
dependent) 18 (2)

1 44
3

(3)

plantar foot pad
(4)

plantar compartment 3
medial, central lateral ( 22.1) 3
compartment plantar fascia metatarsal bones interosseous fascia
compartments

compartments
compartments intercompartmental septa

deep space infection

deep space infection

compartment plantar surface web
spaces
(BK amputation)
(AK amputation) 3
200
22.1 Plantar compartment 3

medial compartment intrinsic muscles
central compartment intrinsic
muscle , extrinsic flexor tendons, vascular arch plantar nerves lateral compartments intrinsic muscles
flexor tendons neurovascular bundles
50
(5)
60
5 (6)

10-15
50(7) 22

13 atherosclerosis
(6,8)
popliteal

metatarsal arteries(9)

aortoliac occlusive disease (AIOD)
microangiopathy
(10)

sorbital
pathway glycolytic pathway
hyperglycemia induced pseudohypoxia

50
(11,12)
progressive distal axonopathy
intrisic
metmatarsal
( 22.2)

autonomic
(12) ( 22.3)

( 22.4)

(2)

201
THE DIABETIC FOOT
Ischemia due to
tibial/peroneal artery
occlusive disease
Toes curled in
claw position
Cavas deformity with

increased pressure
under metatarsal heads
Diminished sensation
22.2 neuropathy, ischemia infection

Acute Soft Tissue Infections

( 10) nail plate (
30) ( 60)(13)
nail plates Keratin
debris media
( 22.1)
acute cellulitis necrotizing fascitis

22.1
ACUTE INFECTIONS
CHRONIC INFECTIONS
Localized cellulitis
Neurotrophic ulcers
Septic arthritis of
Osteomyelitis
metatarsophalangeal joint
Necrotizing cellulitis or fascitis
Deep space infections
Gangrene (clostridial or nonclostridial)
acute cellulitis
tendon deep space infection
necrotizing fascitis
acute necrotizing
ketoacidosis
deep space infection central compartment
lateral medial compartment interosseous fascia
deep compartment
flexor tendon
compartment
intrinsic
muscles
plantar vessels
202
0
I
II
III
IV
V
22.3 Grading of Diabetic Foot Ulcer
Grade O
Grade I
Grade II
Grade III
Grade IV
Grade V
No ulcer but high-risk foot

Superficial ulcer
Deep ulcer, No bony involvement
Abscess with bony invovlement
Localized gangrene (toes, heel)
Gangrene - whole foot

clostridium

clostridium
sepsis
acutely inflamed diabetic foot infection gouty arthritis Charcots joint
gouty arthritis metatarsophalangeal joint

Charcots joint 2.5
metatarsophalangeal, metatarsotarsal, intratarsal interphalangeal
joints
Charcots joint

ESR
Neurotrophic ulcer neurotrophic ulcer

neurotrophic ulcer
claw toe
deformity metatarsal head
plantar pressure(14)
keratosis
plantar tissue metatarsal head 1, 2 5 callus neurotrophic
ulcers
THE DIABETIC FOOT
22.4

plantar surface
osteomyelitis
sinus neurotrophic ulcer deep compartment
deep compartment
osteomyelitis (15,16)
14

CT scan MRI osteomyelitis (17)

atherosclerosis

50
(18)

203
retinopathy

( 22.4)

ankle pressure 80 mmHg
55 mmHg
30 mmHg transcutaneous oxygen (TcO2) tenson 10-20 torr(19)

1.
1.1

1.2

1.3
Lanolin, Eucarin

Desenex
1.4

1.5 corns calluses

osteomyelitis
1.6

1.7

204
2.
2.1
2.2
2.3
3. collateral circulation
3.1

3.2 Intermittent claudication

3.3

4.

4.1

4.2
bacitracin ointment
4.3

4.4
2 corns
calluses
osteomyelitis 2

cellulitis,
3
arteriogram
(20)
Diabetic Foot Infections

2
(21,22,23)

neurotrophic ulcer
specimen (24)
Staph. aureus, group D B Streptococci, E. Coli, Enterobacter aerogenes, Bacteroides
fragilis, Peptostreptococci Clostridium species(24,25)
anaerobes aerobes 10
E. Coli
anaerobes Cephalosporins
Quinolones Clindamycin(22,23)

3rd generation Cephalosporin, Clindamycin, Ticarcillin, Clavulanic acid
Cefoxitin Ceftizoxine
(26)
aminoglycoside
cellulitis deep space infection

10-14
osteomyelitis 4-6
Vancomycin, Teicoplanin Ciprofloxin
(27)

10-14
granulation tissue

205
THE DIABETIC FOOT
22.5
. Plantar incision: web space medial lateral compartments

plantar surface toe pulp longitudinal
. Dorsal incisions: dorsal web space venous arcade
lateral compartment plantar surface
major amputation (AK or BK)

major amputation
retinopathy

(28)

neurovascular bundles ( 22.5)
22.2
Keller bunionectomy
Claw toe correction
Metatarsal head resection
Dorsal wedge osteotomy of the metatarsal shaft
Partial calcanectomy
Preventive operations mechanical trauma plantar surface

metatarsal osteotomies metatarsal head
plantar surface (29,30)
( 22.2)
206
1. Maser RE. Cardiovascular disease and arterial calcification in

insulindependent diabetes mellitus: Interrelations and risk factor
profiles. Arterioscler Thrombos 1991;11:958.
2. Leichter SB. Clinical characteristisc of diabetic patients with serious pedal infections. Metabolism (Suppl 1) 1988;37:22.
3. Wright DG, Desai SM, Henderson WH. Action of the subtalar and
ankle joint complex during the stance phase of walking. J Bone
Joint Surg 1964;46:361.
4. Bojsen-Moller F. Anatomy of the forefoot: Normal and pathologic.
Clin Orthop 1979;142:10.
5. Bouton AJM. Detecting the patient at risk for diabetic foot ulcers.
Practical Cardiology 1983;9:135.
6. Penn I. The impact of diabetes mellitus on extremity ischemia. In:
Kempczinski RF (ed.). The Ischemic leg. Chicago. Year Book Medical Publishers 1985;56-69.
7. Brandman O, Redisch W. Incidence of peripheral vascular changes
in diabetes mellitus. Diabetes 1953;2:194.
8. Haimovici H. Peripheral arterial disease in diabetes mellitus. In:
Ellenberg M, Rifkin H (eds.). Diabetes Mellitus: Therory and Practice. New York: McGraw-Hill 1970;890-911.
9. Ferrier TM. Comparative study of arterial disease in amputated
lower limbs from diabetics and nondiabetics (with special reference
to feet arteries). Med J Aust 1967;1:5.
10. Strandness DE Jr, Priest RE, Gibbons GE. Combined clinical and
pathologic study of diabetic and nondiabetic peripheral arterial disease. Diabets 1964;13:366.
11. Edmonds ME, Watkins PJ. Management of the diabetic foot. In:Dyck
JP, Thomas PK, Lambert Elt, et al (eds.). Diabetic Neuropathy. Philadelphia: WB Saunders 1987;212.
12. Thomas PK, Eliassan SG. Diabetic Neuropathy 2nd ed. Philadelphia: WB Saunders 1984;1773-1810.
13. Bose K. Surgical approach for the infected diabetic foot. In Orthop
1979;3:177.
14. Harrison MJ, Faris IB. The neuropathic factor in the etiology of
diabetic foot ulcers. J Neurol Sci 1976;28:217.
15. Park HM. Scintigraphic evaluation of diabetic osteomyelitis: Concise communication. J Nucl Med 1982;23:569.
16. Sach W, Kanat IO. Radionucleotide scanning in osteomyelitis. J

Foot Surg 1986;25:311.
17. Erdman WA, Tamburro F, Jayson HT, et al. Osteomyelitis. Characteristics and pitfalls of diagnosis with MR imaging. Radiology
1991;180:533.
18. Laing P. Diabetic foot ulcers. Am J Surg 1994;167:318.
19. Cina C. Utility of transcutaneous oxygen tension measurements in
peripheral arterial occlusive disease. J Vasc Surg 1984;1:362.
20. Mueller MP, Wright J, Klein SR. Diabetes and Peripheral Vascular
Disease. In:Veith FJ, Hobson RWII, Williams RA, Wilson SE (eds.).
Vascular Surgery (2nd ed.). New York: McGraw-Hill 1994;514-522.
21. Arcieri G, Griffith E, Gruenwaldt G, et al. Ciprofloxacin: An update
on clinical experience. Am J Med 1987;82:381.
22. Ingram C, Eron LJ, Goldenberg RI, et al. Antibiotic of osteomyelitis
in outpatients. Med Clin North Am 1988;72:723.
23. Lipsky BA, Pecoraro RE, Larson SA, et al. Outpatient management
of uncomplicated lower-extremity infections in diabetic patients.
Arch Intern Med 1990;150:790.
24. Sapico FL, Witte JL, Canawati HN, et al. The infected foot the
diabetic patient: Quantitative microbiology and analysis of clinical
features. Rev Infect Dis 1984;6:S171.
25. Wheat LJ, Allen SD, Henry M, et al. Diabetic foot infections: Bacteriologic analysis. Arch Intern Med 1986;146:1935.
26. Hughes CE, Johnson CC, Bamberger DM, et al. Treatment and
Long-term follow-up of foot infections in patients with diabetes or
ischemia: A randomized, prospective, double blind comparison of
cefoxitin and ceftizoxime. Clin Ther 1987;10(Suppl A):36.
27. Tsukayama DT, Guay DR, Gustilo RB, et al. The efffect of anaerobiosis on antistaphylococcal antibiotics. Orthopedics 1988;11:1285.
28. Fylling CP, Knighton DR. Amputation in the deabetic population:
Incidence, causes, cost, treatment and prevention. J Enterostomal
Ther 1989;16:247.
29. Frykberg RG. Podiatric problems in diabetes. In: Koza KGP, Campbell
C, Hoar CS Jr, et al (eds.). Management of Diabetic Foot Problems.
Philadephia: WB Saunders 1984;58-67.
30. Jacobs RI. Hoffman procedure in the ulcerated diabetic neuropathic
foot. Foot Ankle 1982;3:142.
208
23. Surgical Treatment of Vericose Veins

24. Venous Thrombosis
25.
23
SURGICAL TREATMENT
OF VARICOSE VEINS
varicose veins (vv)
20 (1-4)

(5)

(recurrent rate)
,
(6-10)
,

1o vv
1. superficial venous insufficiency

superficial veins (long saphenous short saphenous) perforating veins(11)
2. subcutaneous tissue
perforating veins
3. venous
hypertension edema, fibrosis, induration,

incompetent perforators endoscopic
subfascial ligation
fascia
perforating veins clip
4. venous ulcers
incompetent lesser saphenous vein
perforating veins
vv
perforating veins superficial vein
(1,2-15)
1. high ligation and stripping of the long saphenous

vein
2. stripping of the short saphenous vein
3. subcutaneous removal of varicosities
4. subfascial ligation of perforating veins
210
vv
1. varicosis
, , night cramps restless leg
2. varicosis hemorrhage, thrombophlebitis dermatitis, pruritus
painful ulcers exposure nerve endings
3. (cosmetic considerations)

non-varicose
I. High ligation and stripping of the long

saphenous vein
epidural anesthesia

genitalia

Trendelenberg position
inguinal ligament 2
10 saphenofemoral junction tributaries 5
long saphenous vein ( 23.2,.3,.4) tributaries 5
inferior epigastric vein long saphenous vein
5 saphenofemoral junction
1.

2. amublate
3. chronic arterial insufficiency

elastic bandage
4. active postphlebitic conditions
5. active superficial thrombophlebitis
6. vv

7.
8.
Brodie-trendelenberg test
Perthes test deep veins

(16)
groin, popliteal fossa local
excision subfascial ligation

( 23.1)
23.1

SURGICAL TREATMENT OF VARICOSE VEINS
211
23.2 inguinal ligament long saphenous vein
23.3 long saphenous vein tributaries 5 inferior epigastric, superficial iliac circumflex, pudendal,
medial lateral femoral veins.
212
23.4 5 long saphenous vein femoral vein
23.5 saphenous nerve long saphenous vein - venous

stripping
23.6 saphenous nerve
23.7 A. stripper long saphenous vein groin

B. stripper stripper T-bar
213
214
23.8 short saphenous vein stripping

popliteal fossa
23.9 sural nerve short saphenous vein
215
23.10 short saphenous vein fascia short saphenous vein Giacomini vein
23.11 lateral malleolus short saphenous vein stripper

short saphenous vein elastic bandage
216
long saphenous vein femoral vein 0.51.0 (flush ligation)
venous injury clamp long
saphenous vein
2-3
long saphenous vein
saphenous nerve long saphenous vein(17) ( 23.5)
stripping
(18) ( 23.6)
long saphenous stripper
groin ( 23.7A)
stripper (18,19)
1.
long saphenous vein
main trunk
main trunk
2. perforators
perforators
tripper
3. stripper
saphenous nerve
lymphatic stripping
2-0 stripper
( 23.7B) stripper T-bar
stripper long saphenous vein

long saphenous vein
fascia
staple suture
elastic bandage

popliteal fossa short saphenous vein

fascia subcutaneous
fascia short saphenous vein
subcutanous sural nerve
( 23.9) short saphenous vein sapheno popliteal junction
Giacomini vein ( 23.10)
short saphenous vein
lateral malleoulus stripper
short saphenous vein tributaries
stripping vein
elastic bandage ( 23.11)
III. Subcutaneous removal of varicostics

(stab avulsions)
skin crease

1 arterial forcep
(20) ( 23.12)
II. Stripping of the short saphenous vein

epidural anesthesia
( 23.8)
23.12 stab avulsions of varices
217
tributaries saphenous veins

stripper perforators

Trendelenberg
bandage
mattress suture
elastic bandage
2.
IV. Subfascial ligation of perforating veins

medial side 1
tibia 15 medial
malleoulus subcutaneous fascia
superficial varicosities
fascia
dilated perforating veins

browny induration
endoscopic subfascial ligation (23)
elastic bandage varicose veins

(24)

metallic clip
compressive stocking
6-8

1. Bleeding ecchymosis
3-5
3-4
elastic bandage
3.
4.
5.
6.
7.
3-4 elastic bandage ecchymosis

elastic bandage
ecchymosis hematoma
Edema
elastic bandage 3-4
lymphatic
drainage
Nerve Damage venous stripping
saphenous nerve

sural nerve
dissect vein nerve stripping groin
stripper neurapraxia
3-4
Wound Infection 1.1%

stripping

Thromboembolic Disease DVT

early ambulation
Induration of the stripper tract
fibrous formation
1-2
Deep vein or arterial stripping
perforator deep vein

218

varicose veins
varicose veins
venous stripping saphenous vein
bypass vascular disease coronary heart
disease varicose veins
valves bypass
high ligation long saphenous vein

(25)

primary varicose vein (primary incompetent symptomatic
veins without skin complications)

3 6

sclerosing agent local stab avulsions
219
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1975;62:913-917.
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220
24
VENOUS THROMBOSIS
venous
thrombosis, valvular incompetence pulmonary embolism

3

factor XIII, prostacycline fibrinolytic
activates
10 elastic tissue media superficial
venules

adventia collagen elastin
vasa vasorum

valves
valves biuspid

valves
inguinal ligament external iliac
vein valve IVC
2 superficial
deep system perforators superficial
veins
thermoregulation greater lesser saphenous veins anteromedial posterior
fascia valves
fascia deep venous system perforators ( 24.1)
10 deep venous
system superficial deep femoral,
popliteal, anterior posterior tibial peroneal veins
2
(venous concomitants) ( 24.2)
90 deep veins form
sinusoids soleus sinusoids
posterior tibial vein ( 24.3)
deep vein
thrombosis perforators fascia
222
Femoral
Superficial epigastric
Superficial
circumflex iliac
Femoral
External pudendal
Saphenofemoral
junction
Great saphenous
Lateral femoral
Medial femoral
Great saphenous
Popliteal
Small saphenous
Perforators
Perforators
24.1 greater lesser saphenous veins greater saphenous vein

saphenofemoral junction
Saphenofemoral junction
Thigh perforators
Lateral thigh perforator
Long saphenous vein
Saphenopopliteal
junction
Boyds perforator
Short saphenous vein

Mid calf perforator
Ankle perforators
24.2 perforating veins medial posterolateral
Soleal perforator
223
VENOUS THROMBOSIS
24.1 venous thrombosis
Giacomini vein
Popliteal vein
Short saphenous vein
Gastrocnemius vein
Mid-calf perforator
24.3 lesser saphenous vein perforator gastrocnemius vein
superficial deep system one-way

valves

200
soleus gastrocnemius sinusoids muscle pump
function
deep veins incompetent valves
VENOUS THROMBOSIS

venous thrombosis
Virchows triad (1856) venous stasis,
epithelial injury hyper coagulability(1,2) ( 24.1)
venous stasis

valvular
incompetence, endothelium
hypercoagulability
(1-5)
40

deep-vein thrombosis
pulmonary embolism
varicose veins

estrogen
Polycythemia
Thrombocytopenia
Connective tissue disease
Congenital coagulation disorders
venous thrombosis 2
1. Deep Venous Thrombosis (DVT)

2. Superficial Venous Thrombosis

greater saphenous vein
DVT
50
dorsiflex (Homans sign)

50 DVT superficial venous
thrombosis
greater lesser saphenous vein(2,6-9)
(9-13)
1. Doppler ultrasonography

doppler

224

retrieving wave

venous flow

venous flow

doppler ultrasound anterior
posterior tibial, popliteal femoral
doppler
ultrasound
1.1

1.2 flow
1.3 flow
DVT
doppler US 80-85

femoral soleal veins

2. Impedance Plethysmography (IPG)

maximal venous output (MVO) venous
capacitant venous capacitant
calf circumference strain
guage
50 DVT
venous capacitance

inflate cuff ( 24.4) MVO
slope curve deflate cuff DVT
slope outflow
delfate cuff IPG DVT
85-95 thrombi

3. Duplex scanner
DVT B-mode ultrasound
Doppler flowmeter

float
valve ( 24.5)
iliac
femoral veins IVC
24.4 Impedance Plethysmography (IPG)

pneumatic cuff ( 50
45 )
venous capacity
cuff
DVT
225
VENOUS THROMBOSIS
24.5 Duplex scan common femoral vein . thrombus lumen ()

. probe thrombus lumen
4. Venogram

venous flow fluoroscopy
termination of
dye column, filling defects, collaterals

( 24.6) invasive diagnostic procedure
thrombophlebitis
95-100 gold standard

5. I125-labelled fibrinogen uptake test

uptake circulating radioactive fibrinogen
thrombus
labeled human fibrinogen screening uptake uptake
20
thrombi
soleal veins sensitivity
detect thrombi

old thrombi
acute DVT 1224 screening test
DVT ( 24.7)
24.6
Venogram left superficial femoral vein
partial obstruction thrombus
24.7 I125-labelled fibrinogen uptake test
226
24.8 Doppler ultrasonography DVT
left ilieofemoral vein

. longitudinal
. transverse probe compression
6. Doppler ultrasonography
DVT
continous wave Doppler ultrasonography
femoral, superficial femoral, popliteal
tibioperoneals spontaneous wave flow
calf thigh compression
variation
DVT 23-88
thrombi

recurrent DVT postthrombotic
syndrome
thrombi ( 24.8)
greater
saphenous anticoagulant thrombus deep thrombophlebitis

72
duplex scan thrombus
perforator deep venous systems suppurative
thrombophlebitis

suppurative thrombophlebitis
Staph. aureus

(14)
1. thrombi
2. thrombus propragation
3. venous valve

pulmonary embolism (PE)
5 DVT PE
PE 25
Thrombophlebitis
superficial thrombophlebitis

greater lesser saphenous
suppurative thrombophlebitis thrombosis
saphenofemoral junction
Deep Vein Thrombosis (DVT)
227
VENOUS THROMBOSIS
DVT
anticoagulant(14,15) anticoagulant

bolus
dose heparin 5,000-10,000

partial thromboplastin time (PTT)
1.5-2.0
Heparin-Induced-Thrombocytopenia
(HIT) (16,17)
(18) Warfarin
3-7 heparin monitor Warfarin prothrombin
time (PT) 1.5-2.0
anticoagulant 3-6
recanalization collaterals
duplex scanning thrombus
Urokinase, Streptokinase tissue plasminogen activator DVT

monitor fibrinogen fibrinolytic
products ( 24.2)
(19,20)
pulmonary emboli
anticoagulant IVC filter
embolizing clot pulmonary artery emboli pelvic veins
Intraluminal Greenfield filter
femoral jugular(21) ( 24.9)
cavel clips IVC(23) anticoagulant
venous insufficiency

24.2 systemic thrombolytic

therapy
Absolute
CVA
Relative
CPR

diabetic hemorrhagic retinopathy
thrombus ileofemoral vein

Phlegmasia Cerulea Dolens (PCD)
(23) Phlegmasia Alba Dolens (PAD)
ileofemoral vein
arterial
spasm 2
PCD PAD venous thrombectomy anticoagulant (23,24)
venous thrombosis distal arteriovenous fistula
(25)
venous thrombosis
DVT PE

DVT(26,27)
1. low-dose heparin 2,500-5,000
12 2
DVT
25 7
0-20
228
Left renal vein
Right renal vein
Heparin
24.9 Canal Interruption . transfemoral . transjugular
Guide wire
Obturator
229
VENOUS THROMBOSIS
2. Intermittent pneumatic calf compression (IPCC)

2
DVT 25 9.3

IPCC
fibrinolytic activity
venous thrombosis
IPCC low-dose heparin
3. Low molecular weight heparin (LMWH)
fractionated heparin anti-factor Xa
venous thrombosis
12 fixed dose
monitor a PTT(28,29,30)
4. Warfarin venous thrombosis
low-dose subcutaneous heparin

prethrombotic state
Warfarin monitor
PT
Vitamin K antagonist
fresh frozen plasma
dermatitis, alopecia, , ,

placenta skin necrosis
loading dose
5. Dextran
factor VIII: vWF
venous arterial thrombosis 500 6% solution 1,000 10% solution
24 72
, pulmonary
edema,
venous thrombosis
,
superficial thrombophlebitis

50
non-invasive duplex scanning
anticoagulants
Phlegmasia
cerulea dolens venous gangrene
venous thrombectomy caval interruption
caval filter
pulmonary embolism (PE)
230
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933-945.
2. Alpert JS, Dalen JE. Epidemiology and Natural History of Venous
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Venous Thromboembolism. Am Heart J 1996;132: 850-855.
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5. Nachman RL, Siverstein R. Hypercoagulable States. Ann Int Med
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6. Prandoni P, Lensing AWA, Cago A, et al. The Long-term Clinical
Course of Acute Deep Venous Thrombosis. Am Coll Phys 1996;125:17.
7. Coon WW. Epidemiology of venous thromboembolism. Ann Surg
1977;186: 149-156.
8. Kakkar VV. Natural history of postoperative deep-vein thrombosis.
Lancet 1969;2: 230-242.
9. Kakkar VV, Lawrence D. Hemodynamic and clinical assessment
after therapy for acute deep vein thrombosis. Am J Surg 1985;150:
54-62.
10. Oliver MA. Duplex scanning in venous disease. Bruit 1985;9:206214.
11. Cornus J, Pearson SD, Creager MA, et al. Importance of Findings
on the Initial Evaluation for Cancer in Patients with Symptomatic
Idiopathic Deep Venous Thrombosis. Ann Int Med 1996;125:785793.
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14. Ginsberg JS. Management of Venous Thromboembolism. New
Eng J Med 1996;335: 1816-1828.
15. Hirsh J, Raschke R, Warkentin TE, et al. Heparin: Mechanism of
Action, Pharmacokinetics, Dosing Considerations, Monitoring, Efficacy and Safety. Chest 1995;108: 2585-2755.
16. Warkentin TE, Chong BH, Greinacher A. Heparin-induced Thrombocytopenia: Towards Consensus. Thrombosis and Hemostasis
1998;79: 1-7.
17. Laster J. The heparin-induced thrombocytopenia syndrome: An
update. Surgery 1987;102:763-771.
18. Hirsh J, Dalen JE, Deykin E, et al. Oral Anticoagulants: Mechanism
of Action, Clinical Effectiveness and Optimal Therapeutic Range.
Chest 1995;108: 2315-2465.
19. Comerota AJ, Aldridge SC. Thrombolytic therapy for acute deep
vein thrombosis. Can J Surg 1992;36: 359-371.
20. Molina JE, Hunter DW, Yedlicka JW. Thrombolytic therapy for
iliofemoral venous thrombosis. Vasc Surg 1992;26: 630-642.
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and pulmonary embolectomy. World J Surg 1978;3:45-59.
22. Silver D, Sabiston DC. The role of vena caval interruption in the
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cerulea dolens and venous gangrene. Heart Bull 1967;16:101-110.
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25
LYMPHEDEMA
intercellular spaces

( 25.1) congeni 25.1

Primary lymphedema
Congenital lymphedema
Lymphedema praecox
Lymphedema tarda

Acquired secondary edema
Acute thrombosis
(Filariasis)
Chronic postphlebitic
Lymphogranuloma
syndrome
venereum

iliac artery
Arteriovenous fistula
tal acquired ( 25.2)

pitting edema

lymphadema celluitis lymphangitis lymphangiosarcoma
,

25.2 lymphedema
1. Primary
2. Secondary (acquired)
Congenital -
Inflammatory-granulo
matous
Praecox - Filarial
Tarda
-
Lymphogranuloma venereum
(35)
Tuberculous
Syphylitic
Recurrent lymphangitis
Postphlebitic
Postphlebitic
Tumor
Toxic
232
25.1

(1) 4
jugular, iliac sacs, cisterna chyli retroperitoneal
system 3-8
thoracic
duct cisterna chyli jugular buds
cysterna chyli thoracic duct

subclavian ( 25.1)
capillaries

valve
collecting lymphatics
intima, media adventitia
elastic fibers

long standing stasis
lymphedema subcutaneous compartments
3 dermal plexus, collecting channels superficial lymphatic trunks
valves valves system
dermis subcutaneous junction
233
25.2
dermal plexus main lymphatic

trunks collecting channels lymphangiograms
deep lymphatic systems
compartments channels deep superficial systems

(2)
deep vessels valves 1
4
popliteal 6-8 medial deep inquinal nodes.
superficial systems lymphangiography

greater lesser saphenous veins.
8 ( 25.2)
lymphangiography
superior inguinal
nodes inferior inguinal nodes(3)
acquired lymphedema
inguinal nodes 2
superficial fossa ovalis deep fatty fissue
femoral sheath iliac
vessels(4)
2
basilic (medial aspect) cephalic (lateral aspect)
axillary nodes ( 25.3)
234
25.3
interstitial space

1.
2.

3.
capillary permeable
interstitial fluid(5,6)
valves
interstitial spaces
ultrafiltrate transudate
arterial system 24
50 arterialcapillary system
venules
0.1
0.1
0.1-0.5 100
6

(6,7,8)
1. interstitial pressure
2. negative positive fluctuation
3.
4. valves
5.
235
LYMPHEDEMA
capillary
chronic lymphedema 5 100
0.1-0.5 0.9
fibrosis (9,10)
1.
metabolic products fibrin fibrous tissue
2. macrophages collagen
lysis
lymphedema ( 25.3)
1. progressive painless swelling
2. nonpitting edema
3. hyperkeratosis,
onychomycosis ( )
4. buffalo hump edema
5. Stemners sign squared toes.
25.3 lymphedema
Limb swelling
Heaviness
Recurrent lymphangitis
Skin changes
Fungal infections
Limb edema
Dorsal buffalo hump
Elephantine distribution
Pink flushed skin color
Lichenification
Peau d orange
Subcutaneous tissue
lacking resilience
chronic lymphedema
Peu d Orange appearance
primary (congenital) secondary (acquired) acquired
filariasis,
, ,
25.4 lymphangitis lymphedema
236
25.5 lymphedema pitting
25.6 25.5 recurrent
edema

lymphangitis 2 chronic
lymphedema
primary secondary lymphedema

cellulitis lymphangitis
( 25.4) lymphangiosarcoma
pitting edema

fibrosis connective tissue chronic
lymphedema hyperkeratosis
non-pitting edema ( 25.6, 25.7)
primary lymphedema
( 25.2)
1. congenital lymphedema
Milroys disease
2. lymphedema praecox
3. lymphedema tarda
35
benign tumor of lymphatics
1. lymphangioma simplex
2. cavernous lymphangioma
fibrous adventitia
3. cystic lymphangioma cystic hygroma
acquired lymphedema
axillary inguinal nodes
237
25.4 venous lymphatic

edema
Venous
1.
2.
Firm
3.
4.
5.
25.7 25.6 buffalo

hump edema stemners sign
squared toes

Wuchereria bancrofti 10-15
radical mastectomy
postmastectomy lymphedema

(11) lymphedema
gradual onset of edema

vascular malformation
Klippel-Trenauney syndrome Parkes-Weber syndrome venous edema capillary perfusion
lymphedema
( 25.4)
venography, lymphangiography CT scan
phlebitis
firm,
Varicosities,
pigmentation

Phlebography
+
result
Lymphangiography rusults
Lymphatic
honey comb pattern compartments

hematoma, obesity, Bakers cyst, osteoarthritis, trauma induced reflex sympathetic dystrophy lipidemia Yellow Nail Syndrome
(YNS)
YNS (12)
1. yellow dystrophic clubbing of the nail
2. primary lymphedema
3. bilateral effusion
noninvasive studies
water volume displacement

imaging studies
1. Lymphoscintigraphy
lymphedema noninvasive study

radiolabeled antimony trisufide human
serum albumin (HSA) interstitial space
238
dual
head gamma counter radiolabelled colloid
lymphedema
92-100(13)
lymphoscintigram (14,15)
1.
2. dermal backflow (cutaneous pattern)

collaterals
3. uptake
4. abnormal tracer accumulation

extravasation, lymphocele lymphangiectasia.
2. Computed tomography CT scan

lymphedema lime CT scan honeycomb appearance subcutaneous
3. Magnetic resonance imaging (MRI)
noninvasive
secondary
lymphedema
vascular malformation soft tissue
tumor(16,17) lipedema
chronic venous edema lymphedema
MRI
lymphoscintigraphy
4. Lymphangiography direct lymphangiography
microvascular lymphatic reconstruction lymphangiectasia chylous reflux chylous ascites abdominal lymph thoracic duct(18)
5

dermal lymphatic outline

27-30 (Ethiodized oil

Ethidol) 10
5 24

deep superficial lymphatic system deep system
deep lymphatic medial malleolus posterior tibial vessels.
lymphangiogram
lymphangitis, , cellulitis, ,
pulmonary embolism,
, , ,
NONOPERATIVE MANAGEMENT
90 ( 25.5)

compression W. bencrofti
Brugia malayi diethylcarbamazine
(Ivermectin) antihistamine
irreversible fibrosis
lymphedema
compression
15 elastic stocking
(19)
long-acting thiazide potassium sparing diuretics. benzopyrones
tissue macrophages
collagen
25.5 Nonoperative Treatment of Primary
Lymphedema
1. Elevation - foot or bed raised 6 inches.

2. External compressin - elastic stocking in termittent compression unit.
3. Diuretics
4. Avoidance of infection - foot hygine (cleansing, antifungal agent): antibiotics early.
239
10
(20)
streptococcus
penicillin
tissue fibrosis
mechanical reduction chronic lymphedema
fibrosis brawny edema
mechanical reduction
45o C
manual lymphatic drainage (MLD)
4 quadrants 2-3
external compression elastic stocking
40-50
sequential air compression

pneumatic boot 4 compartments cuff 90-100
compression: decompression 1:3
2-3 6-8
3-6 80
( 20) ,
DVT
SURGICAL TREATMENT
5-10 lymphedema
(21)
(
25.5)
1.

2. cellulitis lymphangitis
3. intractable pain
4. lymphangiosarcoma
2 excisinal procedures
lymphatic reconstruction
25.5
1. tissue tension
2. gravitational drainage of fluid

3. dehydration
4.
5.
6. surgical reconstruction of the lymphatic drainage
1. Excisional operations

1.1 Charles operation
subcutaneous tissue tibial tuberosity
malleoli ( 25.8) deep fascia
fibrosis

STSG full
thickness

lymphatic reconstruction flap procedures
25.8 Charles operation subcutaneous tissue
240
Touniquet
25.9 Homans operation fibrosed

subcutaneous tissue
1.2 Modified Homans procedure

fibrosed subcutaneous tissue
pneumatic torniquet
medial skin incision
1 tibial border
subctuaneous tissue 1-1.5
skin flap interrupt facia ( 25.9)
elastic stocking

65-80
1.3 Thompsons procedure

subcutaneous flap procedure

longitudinal dermis flap subcutaneous flap flap deep muscular compartment ( 25.10)
subdermal
lymphatic plexus deep lymphatic channels
Homans procedure
2. Lymphatic reconstruction
lymphatic obstruction spontaneous lymphovenous anas-
tomosis omentel implantation

segment patch (mesenteric bride operation)

primary lymphedema diffuse disease

2.1 lymphovenous anastomosis
chronic lymphedema spontaneous lymphovenous anastomosis lymphangiography compensatory mechanism
subcutaneous fibrosis

(22,23)
secondary lymphedema
cellulitis lymphangitis
conservative
lymphangiography CT
scan
venous hypertension
24-48
intermittent compression
42(24,25)
2.2 lymphatic grafting lymphovenous anastomosis postmastectomy lymphedema(26)

PRIMARY CHYLOUS DISORDERS
, ,
1 (100 ) 0.44

primary chylous disorders
congenital lymphangiectasia megalymphatics
(thoracic duct
main lymphatic trunk)
Primary chylous disorders chylous reflux, chylous ascites, chylothorax ( 25.6)
241
Tibialis ant. m.
Ext. hallucis longus m.
25.10 Buried dermis flap (Thompsons procedure) longitudinal demis flap

flap deep muscular compartment
242
25.6 Primary Chylous Disorders.
Essential of Diagnosis
1. Protein - rich, fatty lymph (chyle) accumulations
in a body cavities.
2. Chylous fluid with specific gravity greater than
1.012 g/dL, protein greater than 3 g/dL, and fat
content 0.4-4 g/dL.
3. Incompetent lymphatic valve.
4. Dilatation of lymphatics (lymphangiectasia).
5. Chylorrhea lymph - filled vesicles in the lower
extremity or perineum.
valvular incompetent
perineum

chyuria chyloperitoneum
chylothorax
tracheobronchial tree
protein-losing enteropathy
Secondary chylous disorders
lymphoma
Chylous
ascites chylothorax

hypocalcemia, hypocholesterolemia, lymphopenia

vesicles chylous ascites

chylothorax Sudan fat
stain
contrasty lymphangiography
primary chylous ascites
CT scan MRI
chylous vesicles valvular incompetent

chylous ascites
chylothorax
ascites
pleural effusion ,

medium-chain triglyceride TPN

chylous ascites chylothorax

Intractable, recurring primary chylous ascites

fibrosis
hypoplasia
peritoneal-venous shunt (Lee Veen)
chylothorax
mechanical pleurodesis thoracic duct azygos vein.
243
LYMPHATIC COMPLICATIONS OF VASCULAR SURGERY

regenerate

postbypass edema, lymphocele (
retroperitoneum) lymphatic fistula
chylous ascites chylothorax
aorta
SVC IVC
Postbypass edema infra inguinal bypass
duplex
scan DVT
compressive
stocking 30-40
bypass graft
, mannitol corticosteroid
Lymphatic fistula

implanted
prosthetic graft CT, white cell scan
lymphoscintography(27)

isosulfan
blue dye 1-3

Lymphocele
pseudocapsule
bypass(28)
fistula lymphocele
lymphocele seroma
lymphoscintigraphy ultrasonography lymphocele hematoma

soft tissue infection lymphocele
graft infection

isosulfan blue lymphocele
exposed prosthetic graft
chylous ascites
intra-abdominal mesentenic lymphatic channels
aortic reconstruction(28)

CT scan
chylothorax

aorta

thoracic duct
mechanical pleurodesis chemical
pleurodesis chylothorax.
lateral femoral
artery
femoral sheath medial
popliteal tibioperoneal arteries
vertical
saphenous vein harvesting
244

cisterna chyli L1-L2
IVC abdominal aorta thoracic duct
cisterna chyli 7-0

metallic clip.
lymphedema

subcutaneous edema
brawny edema
external compression

excisional
procedures
245
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246
248
26.
27.
28.
29.
30.
31.
Hemodialysis Access
Lumbar Sympathectomy
26

coronary heart disease
myocardial ischemia infarction
cardiac
enzyme creatinine phosphokinase (CPK-MB), serum
glutamate oxaloacetate transaminase (SGOT) lactic
dehydrogenase (LDH) 8-24
cardiac
renal function atherosclerosis
diabetic nephropathy

aorta
Intravascular space (IVS) Extravascular space (EVS)

48-72 IVS

monitor
CVP, urine output, serum electrolytes

pulmonary toilet
atelectasis pneumonia
mental status
hypoxia arterial blood gases (ABG), , cardiac enzymes, CT scan
ICU psychosis

ICU psychosis
benign condition
sepsis, hypoxia,
electrolyte imbalance,
Anticoagulants antiplatelet agents

antiplatelet agent
aspirin, dipyridamole (persantin) ticlopidine HCL
patency rate
bypass graft low molecular weight dextran
48 (1) embolectomy long

term anticoagulants heparin warfarin
6 (2)
250
Graft evaluation
patency

hematoma, infection deep vein thrombosis (DVT)
bypass

manipulate
arterial spasm
1
duplex ultra-sonography graft patency duplex scan flow velocity, flow disturbances
, retained valves,
pseudoaneurysm arteriovenous fistula duplex scan 4-6
arteriography(3)
failing graft thrombosed

arteriography focal graft stenosis
inflow outflow
bypass graft graft failure

Early graft failure

thrombosis bypass graft
30 failure
graft , ,
inflow outflow
thrombosis bypass graft arteriogram
thrombectomy failure
in situ saphenous vein bypass graft valves
inadequate outflow tunnel
graft bypass graft
graft failure
failure bypass graft

conduit autologous saphenous vein graft viability
circulating blood(4,5)
operative thrombectomy
thrombolytic therapy Urokinase
underlying pathologic factors
graft failure

Infections

fluctuation

direct seedling

(6)
septicemia, , patency graft
granulation tissue
muscle flap skin graft
thrombosis bypass graft

graft extra-anatomical bypass
251
Additional Postoperative
Considerations(5)
revascularization

gangrene
wet-to-dry dressing

wet-to-wet dressing
dressing

, leukocyte count

1. Rutherford RB, Jones DN, Bergentz SE, et al. The efficacy of dextran 40 in preventing early postoperative thrombosis following difficult lower extremity bypass. J Vasc Surg 1984;25:765-773.
2. Flinn WR, Rohrer MJ, Yao JST, et al. Improved long-term patency
of infragenicular polytetrafluroethylene grafts. J Vasc Surg 1988;7:685690.
3. Veith FJ, Weiser RK, Gupta SK, et al. Diagnosis and management
of failing lower extremity arterial reconstructions prior to graft occlusion. J Cardiovasc Surg 1984;25:381-384.
4. Goldsmith J, Fraco CD, Farrel EA, et al. Advances in the surgical
treatment of lower extremity vascular disease. J Am Acad Phys
Assist 1991;4:481-487.
5. Veith FJ. Gupta SK, Samson RH, et al. Progress in limb salvage by
reconstructive arterial surgery combined with new or improved
adjunctive procedures. Ann Surg 1981;194:386-401.
6. Calligaro KD, Veith FJ, Schwartz ML, et al. When is it safe to leave
an infected prosthetic arterial graft in place? In: Veith FJ, ed.
Current Critical Problems in Vascular Surgery, Vol 4. St Louis:
Quality Med Publ 1992;365-370.
252
27

(torniquet)

(branches)

( 27.1)
27.1

254
27.2

27.3 polyproprylene

( 27.2)
polyproprylene 5-0, 6-0 7-0

(interrupted technique)
(continous over and over technique) ( 27.3)

(
27.4 A,B) (autogenous vein graft) (patch graft) (
27.5)

4-8
27.4

255
27.5 patch graft
256
27.6 (autogenous saphenous

vein graft interposition)

2-3

autogenous saphenous vein
graft interposition
( 27.6) Fogarty balloon catheter

1:100

5
(beveled) 45

( 27.7)
polyproprylene
6-0 7-0 180
( 27.8)
180

(all layer)
257
27.7 (beveled) 45

258
27.8 (continuous suture)
27.9 Carrels triangle 120
259
260

horizontal mattress

( 27.10)
27.10 horizontal mattress suture
5

5
Carrels triangle
120 ( 27.9)
1. Rutherford RB, ed. Atlas of Vascular Surgery: Basic Technique and

Exposures. Philadelphia: WB Saunders, 1993.
2. Van Way CW III. Vascular Suture Technique. In: Moore EE, ed.
Critical decisions in Trauma. St. Louis: CV Mosby, 1984;648-652.
3. . . .
2, : 2531;181-188.
4. Veith FJ. Vascular Surgical Techniques. In: Veith FJ, ed Vascular
Surgery. 2nd ed. New York: McGraw-Hill, 1994;1134-1205.
5. Bergan JJ, Yao JST, eds. Techniques in Arterial Surgery. Philadelphia: WB Saunders, 1990.

lateral venorrhaphy

collateral circulation

50
28
HEMODIALYSIS ACCESS

vascular access

(1,2)

1. uremia
BUN
BUN 100 mg/dl

, , myoclonus, asterixis, peripheral neuritis uremic pericarditis
2. hyperkalemia
6 mEq/L
K-bonding resin
3.

4. drug overdose
hemodialysis access life saving

procedure

vascular access

vascular access

vascular access
vascular access
vascular access
vascular access
revise failed access
(invasive radiologic technique)
vascular access
(1,2,3)
vascular access hemodialysis, plasmapheresis, ultrafiltration, charcoal hemoperfusion,
(3)
262
28.1 Hemodialysis Access
263
HEMODIALYSIS ACCESS

hemodialysis

hemodialysis access

6mg/dl
creatinine clearance 10 ml/min
hemodialysis access matured
Dialysis catheter 2
central vein

Arteriovenous fistula (AVF)
high
flow circuit 4-6

Arteriovenous graft (AVG)
(conduit)

AVG
polytetrafluoroethylene (PTFE) graft
Arteriovenous shunt (AVS) externalized communication
silastic tube

Access Axioms

300-400
arterialized vein, central
vein

autologous fistula implanted graft
(1,2,3)
arteriovenous shunt (AVS)
arteriovenous fistula (AVF) Brescia-Cimino
AVF
(4)
access
( 28.1)
1. acute short-term dialysis access
2. acute as well as eventual chronic hemodialysis
access
3. chronic dialysis access without a requirement for
immediate access
I. ACUTE DIALYSIS ACCESS

1.1 direct single-lumen percutaneous puncture
femoral artery
femoral vein access Sheldon femoral catheters
(thrombosis, pseudoaneurysm, arterivenous fistula)

1.2 non-cuffed dual-lumen dialysis catheters
(
28.1) Shiley, Quinton VasCath catheters
2
thrombosis

pneumothorax,
264
Internal Jugular v.
Dacron felt cuff
28.1 non-cuffed dual lumen dialysis catheter

1.3 cuffed dialysis catheter Perm cath
VasCath catheters ( 28.2)
venous cut down

thrombosis
Cephalic vein
Radial artery
Arteriovenous
fistula
28.3 wrist fistula (left arm)
Venous adaptor
(blue)
Arterial adaptor
28.2 cuffed dialysis catheter
II. CHRONIC HEMODIALYSIS

2.1 autologous arteriovenous fistula direct
AVF

(5-8)
3-year patency 70
AVG patency 50 pseudoaneurysm (9-11)
2.1.1 wrist fistula ( 28.3)
cephalic vein

radial artery to cephalic vein fistula (AVF) Cimino-Brescia fistula endto-side side-to-side end-vein
to-side artery venous hypertension (12)
265
HEMODIALYSIS ACCESS
Axillary artery & vein

Brachial artery
Cephalic vein
Radial artery
Basillic vein
Antecubital
arteriovenous
fistula
Ulnar artery
28.4 antecubital fossa
Brachial artery
Transposed brachial
vein
Normal position
of brachial vein
Arteriovenous
fistula
28.5 transposed vein arteriovenous fistula
2.1.2 antecubital fistula ( 28.4)
CB fistula cephalic vein

antecubital fossa
tributaries vein
venous outflow deep
vein
2.1.3 transposed vein arteriovenous fistula (
28.5)

brachial basillic vein
cephalic vein
brachial artery
standard AVF
266
Antecubital vein
Cephalic vein
Radial artery
Brachial artery
Basilic vein
Straight
forearm graft
Ulnar artery
28.6 straight fore-arm graft

2.2 dialysis access grafts

direct AVF
conduit
thrombisis pseudoaneuarysm
(11,15,16)

PTFE tanned bovine carotid artery, Human umbilical vein graft
(HUVG) cryopreserved vein
2.2.1 fore-arm arteriovenous fistula
2.2.1.1 straight fore-arm graft ( 28.6)
radial artery
antecubital fossa
(basilic, cephalic antebrachial veins)
straight graft

radial artery

fistula

2.2.1.2 fore-arm loop graft ( 28.7)
distal branchial artery
antecubital fossa Ucurve
brachial
artery radial artery

2.2.2 upper arm graft access

2.2.2.1 curved upper arm graft ( 28.8)
brachial artery antecubital fossa
dorsal lateral
aspect cephalic, basilic
axillary veins
axillary artery
brachial vein antecubital
fossa
267
HEMODIALYSIS ACCESS
Brachial artery
Cephalic vein
Forearm loop graft
Radial artery
Basillic vein
Antecubital vein
Ulnar artery
28.7 forearm loop graft
Curved upper arm

access graft
Cephalic vein
Axillary vein
Basillic vein
28.8 loop upper arm graft
Brachial artery
268
Axillary artery
Loop upper arm graft
Axillary vein
28.9 looped upper arm graft

2.2.2.2 looped upper arm graft ( 28.9)
axillary artery vein U-curve
antecubital fossa

III. CHRONIC DIALYSIS CATHETER

cuffed dialysis catheter ( 28.2) dual-lumen
catheter internal jugular subclavian veins cut down
upper cephalic jugular veins
thrombosis
Urokinase 5,000-10,000

central vein thrombosis
I.
venous outflow
hemodialysis access

venogram
duplex scan
hemodialysis access

cephalic vein antecubital fossa cephalic vein radial artery
CB fistula
antecubital fossa cephalic vein
antecubital AVF (brachial artery to antecubital
or cephalic veins) basilic vein
ulnar artery to basilic vein AVF

hemodialysis access

269
HEMODIALYSIS ACCESS
II.
hemodialysis access
maturation
arterial steal syndrome

10 torr
hemodialysis access
AVF
direct arteriovenous anastomosis

regional anesthesia
Vancomycin

AVF AVG
thrill venous anastomosis AVF

capillary refill
steal syndrome

stiffness
Fistula and graft maturation
2 AVG mature

thrombosis AVF
2-3 hemodialysis access (17)
1.
2.
3. deep
vein (perforators)
dialysis access grafts

pseudoaneurysm

thrombosis

psudo-aneurysm
hemodialysis access(17-23)
1.
7-20

subclavian, internal jugular vein SVC
Urokinase
5,000-10,000

central vein
AVF
AVG subclavian

2. hemodialysis access
300
15
venous outflow tract, arterial inflow

270
venous outflow inflwo
stenosis arteriography fistulography
3.
fistula
outflow stenosis

thrombus , inadequate outflow vein
graft
failure
(hypercoagulability)
4.
hemodialysis access (dysfunction)

bypass

Urokinase

(late graft occlusion) perianastomotic
neointimal hyperplasia venous outflow
6 2
2
fibrous ingrowth

5. arterial steal syndrome low resistance
venous outflow
fistula low resistance venous outflow

fistula
fistula mature
fistula
fistula

fistula perfusion
steal syndrome
ischemic
rest pain

bandaging fistula outflow tract
6. highflow AVF AVF

hypertrophic cardiomyopathy

fixed flow resistant
high outflow AVF bandaging
fistula
7. direct autogenous AVF

AVF
media

Staph.aureus
Staph.epidermidis hemodialysis access

dialysis access

271
HEMODIALYSIS ACCESS

cellulitis

cellulitis

8. aneurysm pseudoaneurysm
aneurysm AVF high velocity turbulent flow aneurysm
AVF

pseudoaneurysm
organized thrombus subcutaneous tissue

hemodialysis access

hemodialysis access
dialysis
access
autogenous vascular conduit
272
1. Bennion RS, Wilson SE. Hemodialysis and Vascular Access. In:Moore

WS (ed). Vascular Surgery: A Comprehensive Review. 4th ed.
Philadelphia:WB Saunders 1993;606-625.
2. Bennion RS, Kempe DA. Arteriovenous Access. In: Strandness ED,
van Breda A. (eds). Vascular Disease: Surgical and Interventional
Therapy. New York: Churchill Livingtone 1994;1045-1106.
3. Wilson ES. Vascular Access Surgery. Chicago:Year Book Medical
Publishger 1988.
4. Byrne C, Vernon P, Cohen JJ. Effects of age and diagnosis on
survival of older patients begining chronic dialysis. JAMA
1994;271:24-31.
5. Brescia MJ, Cimino JE, Apple IC, et al. Chronic hemodialysis using
venipuncture and surgically created arteriovenous fistula. N Engl J
Med 1996;275:1089-1092.
6. Laohapensang K, Lumlertkul D, Pongcheowboon A. Complications
of Vascular Access Surgery. Thai J Surg 1992;13:86-90.
7. Ehrenfeld WK, Gransz H, Wylie EJ. Subcutaneous arteriovenous
fistulas for hemodialysis. Am J Surg 1972;124:200-206.
8. Zibari GB, Rohr MS, Landreneau MD, et al. Complications from
permanent hemodialysis access.
9. Bell DD, Rosenthal JJ. Arteriovenous graft lift in chronic hemodialysis: A need for prolongation. Arch Surg 1988;123:1169-1172.
10. Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for
hemodialysis: Patency rates and results of revisions. Ann Surg
1985;202:235-239.
11. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, et al. Comparison
of autogenous fistula versus expanded polytetrafluoroethylene
graft fistula for angioaccess in hemodialysis. Am J Surg 1986;
152:238-243.
12. Wedgwood KR, Wiggins PA, Gillou PA. A prospective study endto-side v.s. side-to-side arteriovenous fistula for hemodialysis. Br J
Surg 1984;71:640-642.
13. Rivers SP, Scher LA, Sheehan E, et al. Basilic vein transposition:
An underused autologous alternative to prosthetic dialysis
angioaccess. J Vas Surg 1993;18:391-397.
14. Lo Gerfo FW, Menzoian JO, Kumaki DJ, et al. Transposed basilic
vein brachial arteriovenous fistula: A reliable secondary access procedure. Arch Surg 1978;113:1008-1010.
15. Bhat DJ, Tellis VA, Kohlberg WI, et al. Management of sepsis
involving expanded polytetrafluoroethylene grafts for hemodialysis
access. Surgery 1980;87:445-450.
16. Tordoir JH, Herman JM, Kwan TS, et al. Long-Term follow up of
the polytetrafluoroethylene (PTFE) prosthesis as an arteriovenous
fistula for hemodialysis. Europ J Vasc Surg 1988;2:3-7.
17. Thomsen MB, Deurell SI, Elfstrom J. What cause the failures in
surgically constructed arteriovenous fistulas? Act Chir Scand
1983;149:371-376.
18. Laohapensang K, Salvage of the failing vascular access. J Int Coll
Surg Thailand 1992;13:86-90.
19. Zeit RM, Cope C. Failed hemodialysis shunts: One year of experience with aggressive treatment. Radiology 1985;154:353-356.
20. Leny SS, Sherman RA, Nosher SL. Value of clinical for detection of
asymptomatic hemodialysis vascular access stenoses. Angiology
1992;43:421-424.
21. Mattson WJ. Recognition and treatment of vascular steal secondary to hemodialysis prostheses. Am J Surg 1987;154:198-201.
22. Bone GE, Momajzl MJ. Management of dialysis fistula thrombosis.
Am J Surg 1979;138:901-906.
23. Corry RJ, Patel NP, West JC. Surgical management of complications of vascular access for hemodialysis. Surg Gynecol Obstet
1980;151:49-53.
29
(civilian injury)

32 .. 2533 48
.. 2536 ( 29.1)

Iatrogenic injury
blood gas
.... 2533-2536 142

45 (31.7%)
87 (61.3%) 5 (3.5%)
5 (3.5%) ( 29.2)

29.1
..2533-2536
..
2533
2534
2535
2536

32
42
39
48
29.2 142
..
2533-2536
(blunt)
(penetrating)
(blast)
Iatrogenic
45
87
5
5
31.7
61.3
3.5
3.5
274
Inflammatory
reaction
Spasm
Extrinsic compression
(dislocation of knee)
Thrombosis
Intimal injury
Intimal tear
29.1

popliteal
subintimal hematoma, intimal tear thrombosis
Subintimal hematoma
275
high velocity
missle (>2,500 /)

(shot gun
wounds) (<2,000 /)

posterior dislocation
popliteal ( 29.1)
intimal disruption thrombosis

( 29.2)

( 29.3)

chronic venous insuffciency
29.2

intimal disruption thrombosis
276
Thyrocervical trunk 1
Submandibula 1
Vertebral 2
Ext. carotid 1
Int. carotid 1
Thyroid 2
Common carotid 4
Abdominal aorta 2
Hepatic a. 2
Renal 2
Splenic 1
S. mesenteric 6
Inf. epigastric 1
Ext. iliac 2
Common femoral 5
Gluteal 1
Subclavian 7
Thoracic aorta 5
Axillary 7
Branchial 19
Radial & Ulnar 8

Common iliac 2
S. femoral 18
Popliteal 20
Ant. and post. tibial 11
Jugular 9
Subclavian 1
Brachial 2
Innominate 1
Axillary 2
IVC 8
Renal 2
Meseneric 1
Iliac 2
Femoral 2
29.3

142 (25332536)
Popliteal 8
Tibial 1
277

1. Contusion intramural hematoma
hematoma

pseudoaneurysm arteriogram
contrast column
2. Intimal disruption

arteriogram
intimal flap
3.
arteriogram

expanding pseudoaneurysm
arteriogram
4.

thrombus

pulsatile hematoma pseudoaneurysm
( 29.4)
5. arterial spasm

(
29.5)

arteriogram
29.4 pseudoaneurysm superficial
29.5 arterial spasm
femoral artery
278
Hards signs
29.6
superficial femoral arteriovenous
fistula
6. arteriovenous fistula

arteriogram early venous filling ( 29.6)
7. Transection
thrombus

arteriogram
1.
2.

6 Ps (pulselessness, pallor, paresthesia, pain, paralysis poikilothermia)
3. (hematoma)
4. thrill bruit
pseudonaneurysm arteriovenous fistula
hard signs

arteriography

30-40 (1-3)
Soft signs
1.

2.
3.
4.
5.
soft signs
75-80
arteriogram

10-30
(1,2,4)

intimal tear arteriovenous fistula
279

cardiac tamponade

mediastinum hemothorax

arteriogram CT scan(5,6)

ABI duplex scan
ARTERIOGRAPHY
arteriography (7)
1.
2. (exclusive arteriography)
3.
arteriography (8)
1. (shot gun)
2.
3.
4.
5.
arteriography

20-30
arteriography
92(9) arteriogram

arteriography

single shot arteriography
(10)
soft signs
arteriography hard signs

torniquet
collaterals
arteriography
single shot arteriography

tamponade effect

tibial arteries
radial ulnar arteries

intimal disruption

distal circulation
(11)
1. intimal defect
2. pseudoaneurysm 5
3. intimal flap
280
duplex scan arteriography

transluminal embolization
dianostic arteriography (12)
1. low-flow arteriovenous fistula
2. pseudoaneurysm
3. active bleeding
distal profunda femoris muscular branches
4. external carotid artery vertebral hypogastric artery

resuscitate

proximal distal control

preserve superficial venous
drainage
deep vein thrombosis
cephalic vein

median sternotomy lateral thoracotomy

(13)

(13-16)
1.
(anesthetic and paralyzed
limb)
2.
6

3.
(crush) 6-8

degloving
4.

6-8

Vascular control

sponge stick
Foleys catheter
281
Heparin
Fogarty
Arteriiogram
29.7 intraluminal arterial and venous shunt
warm
ischemic time

Fogarty
catheter
1:100

( 29.7)
2

4 Polyproprylene 7-0 (interrupted suture)

hypogastric artery

cephalic vein
autogenous vessels

8
polytetrafluoroethylene (PTFE)
1-5(17,18)

6-8
intraluminal shunt
( 29.8)
intraluminal
shunt

fasciotomy
intraoperative
arteriography
distal arterial spasm
papaverine tolazoline
arterial spasm compartment syndrome

IVC
iliac veins PTFE
saphenous
vein graft

venous collaterals

venous hypertension
stasis

282
29.8
Fogarty balloon catheter
1:100 10-15
intraoperative arteriography
COMPARTMENT SYNDROME

fascial sheath compartment
compartment
( 29.9) compartment syndrome

(19,20)
compartment syndrome
1. compartment

reperfusion injury
oxygen-derived free radicals

cell membrance

venous hypertension

2.
MAST-G-SUIT

passive stretching
compartment compartment
283
Superficial
peroneal
nerve
Lateral
fasciotomy
Fascia deep department

Anterior
fasciotomy
Deep
posterior
fasciotomy
Intermuscular
septum
Superficial
posterior
fasciotomy
Tibia
Saphenous
vein & nerve
Fascial septum
Superficial
peroneal
nerve
Lateral View
Medial View
29.9 fasciotomy

arteriogram
arterial spasm compartment
40 20

myoglobinuria
hyperkalemia

compartment 40 decompressive
fasciotomy (21)
prophylatic fasciotomy
1.
6
2.
3.
4.
5.
6.
fasciotomy
compartment

fasciotomy

(22-24)
4 compartment ( 29.10)
fasciotomy 4
(25) 2
tibia decompress
superficial deep posterior compartments
284
Anterior tibial art. and vein
Tibia
Anterior compartment
Superficial peroneal nerve
Interosseous septum
Deep posterior compartment
Flexor digitorum
longus muscle
Lateral compartment
Fibula
Posterior tibial
art. and vein
Flexor hallucis longus muscle
Tibial nerve
Peroneal art. and vein

Superficial posterior compartment
29.10 compartments 4
saphenous vein nerve
subcutaneous tissue
superficial posterior compartment
origin soleus
tibia deep posterior compartment
tibia fibula
anterior compartment intermuscular
septum decompress lateral compartment
superficial peroneal nerve
septum
2 compartments volar dorsal
decompress compartments
volar ( 29.11) medial epicondyle humerus antecubital fossa
aspect
flexor
retinaculum carpal tunnel decompress median
nerve dorsal compartment dorsal lateral epicondyle
fasciotomy
fasciotomy


loop diuretics
furosemide mannitol mannitol
285
Anterior fasciotomy
Flexor digitorum
superficialis muscle
Flexor carpi
radialis muscle
Investing fascia
Radius
Ulna
Extensor
digitorum muscle
Extensor digitorum
minimi muscle
Posterior fasciotomy
Volar
Dorsal
29.11 fasciotomy
free radical scavenger
reperfusion injury
myoglobin
sclerosis thrombosis

femoral vein deep vein thrombosis

septic thrombophlebitis Staph. aureus
thrombectomy
femoral vein pseudoaneurysm
pseudoaneurysm
mycotic aneurysms

pseudoaneurysm
bacterial
286
emboli vasa vasorum
50
mycotic aneurysm bruit

AV fistula 5
aneurysm thrombosis
distal embolization(26,27)

revascularization

extra-anatomical bypass (28)
revascularization

revascularization (29)
Arterial injection

intra-arterial injection radial branchial

arteries

thrombosis
thrombosis
capillary hydrostatic pressure
tissue perfusion
thrombosis
(30)

cyanosis

arteriogram thrombosis digital arteries
(31,32)
1. 100,000
PTT 1.5-2.5
thrombus propragation
2. dexathethasone 4
6
3. low molecular weight dextran (Dextran 40)
20
4.
5.
6.
contracture

3-8

IATROGENIC INJURIES
monitor

pseudoaneurysm A-V fistula(33-36)

1-2(36,37) branchial
femoral cardiac catheterization

thrombosis (36-39)

1. intimal disruption dissection
thrombus

2. intima ulceration

3. thrombus

pseudoaneurysm colorflow duplex scanning AV fistula murmur
thrill

axillary artery
brachial plexus pseudoaneurysm
thrombosis
A-V fistula

arteriogram
doppler ultrasound

intrinsic muscle

arteriogram
renal artery
vein
kidney function
celiac trunk hepatic artery
hepatic function intestinal viability
arteriogram
48-72
7-10
287

thrombosis

thrombosis
intraoperative arteriography
monitor
doppler ultrasound

pseudoaneurysm chronic osteomyelitis
debridement

pseudoaneurysm
arteriovenous fistula delayed
thrombosis
causalgia

delayed nerve ischemia

dysfunction sympathetic block
sympathectomy
288
1. Laohapensang K, Prathnadi P. Traumatic arterial injuries of the

upper extremity. Thai J Surg 1993;14: 39-42.
2. Feliciano DV, Bitonde CG, Mattox KL, ed al. Civilian trauma in the
1980s. Ann Surg 1984;199:717-724.
3. Munoz E, Cohen J. Epidemiology and the economics of vascular
trauma. In: Civilian Vascular Trauma. Flanigan DP, Schuller JJ, Meyers
JP (eds.) Lea & Febiger, 1992.
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1970;172: 351-360.
5. Stiles QR. Management of injuries of the thoracic and abdominal
aorta. Am J Surg 1985;150:132.
6. Weaver FA. Injuries to the ascending aorta, aortic arch and great
vessels. Surg Gynecol Obstet 1989;169:27.
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289
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290
30

..1500 Ambroise Pare

8-12
elective

1.
1.1
(1)

severe crush injury

open amputation
(stump)
(2)

(1,2,3)
1.2
wet gangrene

guillotine
amputation
(4,5,6)
1.3 8-12

systemic toxicity myonecrosis

myoglobinuria LDH (lactate dehydrogenous isoenzyms)
292
30.1 Toe amputation
2.
2.1
chronic limb threatening ischemia
revascularization ischemic rest pain

tarsal
revascularization
(7,8)
2.2 neurotrophic ulcer

80 90

noninvasive test

(9,10,12)
1.
2. perfusion
3.

noninvasive test
(12-17)
1. segmental blood volume pulse volume recording (PVR) doppler ultrasound pulsatile blood flow PVR tracing
2. skin blood flow testing laser doppler
velocimetry
local skin fluorescence

magnetic resonance (MR) limb blood flow scanning perfusion
3.

thermographic mapping

4. transcutaneous oxygen pressure measurment
(TCPO2)
25
(18-22)
1. (toe ampulation)
( 30.1)
periosteal elevator
periosteum
metatarsophalangeal joint
Ronguer

(interrupted vertical mattress)

2. Ray amputation
metatarsophalangeal crease
293
30.2 Ray amputation
30.3 Ray amputation of great toe
metatarsophalangeal crease (
30.2A) phalanx periosteal
elevator tendon metatarsophalangeal head
Ronguer metatarsal head tendon

( 30.2B)
( 30.3)
3. Transmetatarsal amputation
metatarsal crease
posterior flap
metatarsal
shaft 5-10 ( 30.4)
metatarsophalangeal crease

tendon plantar flap subcutaneous

A
B
30.4 Transmetatarsal amputation
30.5 Symes amputation
294
4. Symes amputation (ankle disarticulation)
ankle crease (
30.5)
medial lateral tarsal branches
talus
anterior tibial tendon talotibial joint
medial lateral collateral ligaments joint
capsule disarticulate talus calcaneus
tibia
fibula heel flap
tibia
Anterior
compartment
5. Below-knee (BK) amputation

long
posterior myocutaneous flap tibia
12 tibial tuberosity
1
( 30.6)
greater lesser saphenous vein
sural verve neuroma
anterior compartment anterior
tibial neurovascular bundles
tibia 2
45o fubula
Tibia
Anterior tibial
vessels and deep
peroneal n.
Lateral
compartment
Peroneal
vessels
Posterior tibial
vessels and tibial n.
30.6 Below-knee amputation
Greater
saphenous v.
Posterior
compartment
Lesser saphenous v.
295
Rectus femoris tendon
Vastus medialis m.
Popliteal a and v.
Vastus lateralis m.
Adductor magnus tendon

Saphenous nerve
Femur
Sartorius m.
Biceps femoris m.
Greater saphenous v.
Tibial n.
Common peroneal n.
Semitendinous m.
Gracilis m.
Semimembranosus m.
30.7 Above-knee
tibia 2 posterior group muscles
posterior tibial peroneal neurovascular
bundles soleal veins posterior flap

soleus
flap

3
6. Above-knee (AK) amputation

BK amputation
femur

femur 2-3
patella femoral condyles (
30.7) greater saphenous vein
femoral vessels
femur
bone wax
296
AK BK amputation
soft ragid dressing immediate
postoperative prostheses (IPOP)

plate
IPOP

dressing

rigid dressing

stump mature
soft dressing
Rays amputation

transmetatarsal amputation

Symes amputation
10
(energy expenditure)
BK amputation
4060
BK amputation
wheel chair
Phantom limb pain

5-30

(23)

10 AK amputation
40 BK amputation

-

wheel chair

297
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11. Malone JM, Moore WS, Leal JM, et al. Rehabilitation for lower
extremity amputation. Arch Surg 1981;116:93-101.
12. Barnes RW, Shanik GO, Slaymaker EE. An index of heshing in
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13. Cheng EY. Lower extremity amputation level using noninvasive

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1982;63:475-481.
14. Holloway GAJr, Burgess EM. Cutaneous blood flow and its relation
to healing of below knee amputation. Surg Gynecol Obstet
1978;146:750-757.
15. Burgess EM, Matsun FA, Wyss CR, et al. Segmental transcutaneous
measurement of PCO2 in patients requiring below knee amputation
for peripheral vascular insufficiency. J Bone Joint Surg (Br)
1982;64:378-382.
16. Katsumouris A, Brewster DC, Magermen J, et al. Trancutaneous
oxygen tension in selection of amputation level. Am J Surg
1984;147:510-515.
17. White RA, Nolen L, Hanley P, et al. Non-invasive evaluation of
peripheral vascular disease using transcutaneous oxygen tension.
Am J Surg 1982;144:68-74.
18. Sizer JS, Wheelock FC. Digital amputations in diabetic patients.
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19. Roon AJ, Moore WS, Goldstone J. Below-knee amputation: A modern approach. Am J Surg 1977;134:153-160.
20. Fearon J, Campbell DR, Hoar CS, et al. Improved results with diabetic below-knee amputations. Arch Surg 1985;120:777-782.
21. Lipski BA, pecoraro RE, Larson SA, et al. Out patient management
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Arch Intern Med 1990;150:790-794.
22. Larsson U, Andersson GBJ. Partial amputation of the foot for uncomplicated lower-extremity infections in diabetic patients. Arch
Intern Med 1990;150:790-796.
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298
31
LUMBAR SYMPATHECTOMY
.. 1727 du Petit vascular tone
sympathetic nervous system .. 1924 Royle lumbar
sympathectomy spastic paralysis(1)
Julio Diez sympathectomy arterial occlusive disease .. 1950
1960 sympathectomy limb
ischemia atherosclerotic occlusive disease(2)
femorodistal bypass severe limb ischemia .. 1970
sympathectomy sympathectomy
cutaneous
blood flow
lumbar sympathetic trunk

medial arcuate ligament extraperitoneum
psoas fascia lumbar segmental vessels medial border psoas
lumbar vertebrae transverse process
( 31.1) IVC
aorta 4 lumbar ganglia visceral
branches somatic branches lower

abdominal wall
sympathectomy
sympathectomy
sympathectomy
1/3
(3-8) lumbar
sympathectomy

vasomotor activity L2 - L3
, ( 31.2) L1
ganlia (ejaculation)

(9) L1 crus of diaphragm
ganglia 4 ( 28) L2 L4 L4
iliac vessels L1 L2
L2 L1 L2
L3 ganglia vasomotor tone
300
Inf. vena cava
Abdominal aorta
Ureter
Transversalis fascia
Kidney
Quadratus lumborum
Lumbar vertebra
Psoas major
Sympathetic trunk
31.1 Retroperitoneum transversalis fascia (......)
L1
L2
L3
L1
L2
L2
L3
L3
Bilateral lumbar
sympathectomy
31.2 sympathectomy ganglia L1 - L3 L2

L3
301
(10) anatomical variation

crossover nerve fibers 15
sympathectomy ganglia regeneration nerve fibers

complete sympathectomy
iodine starch test cobalt
triketohydrinedene hydrate (Ninhydrin) (11)
sympathectomy
(3-8,12,13)
1.
arterioles cutaneous vascular
beds AVM
2. nutritive flow distal cutaneous
beds
3. ischemic rest pain non vascular effect
sympathectomy O2
demand: supply ratio pain receptor.
sympathectomy
1. causalgia reflex dystrophy
, hypesthesis,
trophic
change (14) 4060 , ,
tricyclic antidepressants, alpha2-adrenergic blockers 3
multiple translumbar sympathetic block
sympethectomy(15)
2. Inoperable arterial occlusive disease
reconstruct bypass (16)
2.1 rest pain criteria
1. A.B.I. 0.3
2. neuropathy
3. sympathetic block
2.2 limited tissue loss criteria

1. A.B.I. 0.3
2. neuropathy
3. gangrene
4. major deep infection
3. lower extremity vasospasm(17)
lumbar sympathectomy aortoiliac
femoropopliteal bypass (18)
sympathectomy ischemia degeneration
(19)
Smithwick test
sympathectomy
maximal tissue anoxia vasodilatation collaterals
capillary refilling time 20-30
sympathectomy Smith wick
test capillary refilling time
30 arterial capillary reserve
sympathectomy (2)
CHEMICAL SYMPATHECTOMY

x-ray control spinous
process L2 L3 3 midline
canula anteromedially lumbar
vertebral body
body vertebra
Phenol
(20,21)

L3 contrast media x-ray
CT needle
guidance 7.5 7.5% Phenol
50% glycerine L3
Phenol sympathetic chain
chemical sympathectomy
somatic nerve paresis(22)
302

,
steri-drape

Incision 3
15
1. external oblique
lateral 1/3 anterior rectus sheath (
31.3)
External oblique muscle
2. rectus medial lateral margin posterior rectus sheath

extraperitoneal plane peritoneum deep
surface transversus abdominis
blunt dissection peanut sponge stick
internal oblique transversus abdominis neurovascular bundles
3. free peritoneum lateral medial sponge stick psoas

peritoneum
ureter peritoneum forcep
ureter peristalsis
External oblique aponeurosis
Rectus muscle
31.3 right lumbar sympathectomy
303
genitofemoral psoas
sympathetic trunk
lateral ( 31.4) ganglia
4. lumbar trunk
lateral aorta
IVC
Deaver retractor
IVC
5. mobilize L2 L3 nerve hook sympathetic trunk forcep ( 31.5)
clip metallic clips sympathetic
trunk
6.

sympathetic chain
lumber vessels packing metallic clips
IVC aorta
iliac vessels
ureter peritoneum peritoneum
neurovascular bundles
genitofemoral iliolumbar nerve sympathetic chain
neuritic pain
lumbar sympathectomy
adhesions sympathetic chain
Inferior vena cava
Nerve hook
Psoas muscle
31.4 sympathetic chain
304

rest pain
6
(23,24)
paralytic
ileus 2-3 rectal
tube

1. postsympathectomy neuralgia
10-14
hypesthesia
anterolateral
6
sensory
motor
2. L1 ganglia
(ejaculation)

3. sympathetic regeneration
sympathetic activity
sympathetic trunk clip
metallic clip
sympathectomy neurovascular pain

cutaneous nutritive flow
ischemic pain perception
causalgia coldinduced vasospasm
sympathectomy microcirculatory hemodynamics end-stage arterial occlusive disease
prostacycline analogues
31.5 sympathetic chain
305
1. Royle ND. A new operative procedure in the treatment of spastic

paralysis and its experimental basis. Med J Aust 1924;1: 27-81.
2. Thimming RF, Smith MB, Sullivan JM. Lumbar sympathectomy in
the treatment of arteriosclerotic peripheral vascular disease. Surg
Clin North Am 1958;38: 1081-1092.
3. Rutherford RB, Velenta J. Extremity blood flow and distribution:
The effects of arterial occlusion, sympathectomy, and exercise.
Surgery 1971;69: 332-344.
4. Moore WS, Hall AD. Effects of lumbar sympathectomy on skin
capillary blood flow in arterial occlusive disease. J Surg Res 1973;14:
151-157.
5. Collins GJ Jr, Rich NM, Clagett PG, et al. Clinical result of lumbar
sympathectomy. Am Surg 1981;47: 31-35.
6. Persson AV, Anderson LA, Padberg FT Jr. Selection of patients for
lumbar sympathectomy. Surg Clin North Am 1985;65: 393-402.
7. Welch GH, Lieberman DP. Cutaneous blood flow in the foot following lumbar sympathectomy. Scand J Clin Lab Invest 1985;46: 621626.
8. Walsh JA, Glynn CJ, Cousins MJ, et al. blood flow, sympathetic
activity and pain relief following lumbar sympathetic blockade or
surgical sympathectomy. Anesth Intensive Care 1985;13: 18-25.
9. Quale JB. Sexual function after bilateral lumbar sympathectomy
and aortoiliac bypass surgery. J Cardiovasc Surg 1980;21: 215-224.
10. Callow AD, Simeone FA. The Grimonster symposium. Arch Surg
1978;113:295-301.
11. Benzon HT, Cheng SC, Avram MJ, et al. Sign of complete sympathetic blockade: Sweat test in sympathogalvanic response. Anesth
Analg 1987;122: 668-673.
12. Cronenwett JL, Lindenauer SM. Hemodynamic effects of sympathectomy in ischemic canine hind limbs. Surgery 1980;87: 417-424.
13. Cross FW, Cotten LT. Chemical lumbar sympathectomy for ischemic rest pain: A randomized, prospective controlled clinical trial.
Am J Surg 1985; 150: 341-349.
14. Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy: A
review. Arch Neurol 1984;41: 821-830.
15. Mockus MR, Rutherford RB, Rosales C, Pearce WH. Sympathectomy for causalgia: Patient selection and long-term results. Arch
Surg 1987;122: 668-677.
16. Rutherford RB, Shannon FL. Lumbar sympathectomy: Indication
and Technique. In: Rutherford RB (ed.). Vascular Surgery 4th ed.
Philadelphia: WB Saunders, 1995;874-883.
17. Janoff KA, Phinney ES, Porter JM. Lumbar sympathectomy for
lower extremity vasospasm. Am J Surg 1985;150: 147-158.
18. Lee BY, Thoden WR, Madden JL, et al. Long-term follow-up of
bypass procedures with and without lumbar sympathectomy.
Contemp Surg 1982;20: 51-59.
19. Danalle MJ, Bauman FG, Mintzer R, et al. Limited success of the
lumbar sympathectomy in the prevention of ischemic limb loss in
the diabetic patients. Surg Gynecol Obstet 1981;152: 784-792.20.
Hoxton HA. Paravertebral block with aqeous phenol in the treatment of vascular disease. Angiology 1953;4: 268-279.
21. Reid W, Kennedy Watt J, Gray TG. Phenol injection of the sympathetic chain. Br J Surg 1973;57: 45-56.
22. Smith RC, Davidson NM, Ruckly CV. Hazard of chemical sympathectomy. Br J Med 1978;1: 552-561.
23. Yao J ST, Bergan JJ. Predictability of vascular reactivity relative to
sympathetic ablation. Arch Surg 1973;107: 676-680.
24. Walker PM, Johnston KW. Predicting the success of a sympathectomy: A prospective study using discriminant function and multiple
regression analysis. Surgery 1980;87: 216-224.
306

A
abdominal angina 20
above-knee (AK) amputation 295
acquired aneurysm 23
acquired lymphedema 235, 236
acrocyanosis 22
acute arterial occlusion 177
acute arterial thrombosis 22
acute cellulitis 201
acute limb ischemia 177
acutely inflamed diabetic foot infection 202
Adam kevics artery 122
adductor canal 159
air plethysmography 60
aldosterone 150
Allens test 110, 144
alpha-1-antitrypsin 116
alpha-globulin 150
amaurosis fugax 20, 93
Ancrod 47
aneurysm 115, 271
aneurysmorrhaphy 119
angioscopy 75, 184
angiotensin 150
angiotensin I 150
angiotensin II 150
angiotensin-converting enzyme (ACE) inhibitors 156
ankle disarticulation 294
ankle Pressure Index 13
ankle-brachial index (ABI) 137
ankle-brachial pressure indices 63
antecubital fistula 265
anticoagulants 45
antiplatelet agents 43
antiserotonin drugs 139
aorto-duodenal fistula 116
aortocaval fistula 116
aortoiliac surgical reconstruction 132

aortorenal bypass 154
arterial autografts 81
arterial infection 189
arterial lines 143
arterial plethysmography 60
arterial spasm 277
arterial steal syndrome 270
arteriomegaly 39
arteriovenous fistula 278
arteriovenous fistula (AVF) 263
arteriovenous graft (AVG) 263
arteriovenous O2 gradient 137
arteriovenous shunt (AVS) 263
arteritis 173
aspirin 138
asymptomatic AAA 115
asymptomatic carotid stenosis 95
asymptomatic Hollen-horst plaque 95
atherectomy devices 76
autogenous reversed saphenous vein graft 82
autogenous saphenous vein graft interposition 256
autologous fistula 263
autotransfusion 120
axillofemoral bypass 132
B
bacterial endocarditis 189
balloon catheter 177
balloon tipped catheter 5
below-knee (BK) amputation 294
berry aneurysm 23
biplane aortography 118, 130
blue toe syndrome 127, 159, 178
Branhams bradycardia response 32
brawny edema 27
Brescia- Cimino fistula 6
Brescia-Cimino AVF 263
308
Brodie-trendelenberg test 210
brown pigmentation 25
brownish skin pigmentation 28
Brugia malayi 238
Buergers angle 9
Buergers disease 167
buffalo hump 235
C
calcium-channel blockers 139
calf claudication 168
capillary filling time 10
capillary refilling 12
capillary refilling time 110, 301
captopril renal scaning 150
captopril test 150
carbondioxide arteriography 153
cardiac catheterization 88, 286
cardiac tamponade 279
carotid barorecoptor trauma 103
carotid body tumor 95
carotid endarterectomy 98
carotid pseudoaneurysm 104
causalgia 287, 301
caval filter 229
caval interruption 229
cavernous lymphangioma 236
cerebro vascular accident 20
cervical rib 110
cervical rib syndrome 21
Charles operation 239
chemical sympathectomy 301
chronic venous insufficiency 27
chylothorax 243
chylous ascites 243
circulation - enhancing drugs 47
claudication distant 15
claudication time 15
claw toe deformity 202
clinical vascular laboratories 59
coarctation of the aorta 20
cobble stone 32
cockscrew appearance 169
color duplex scanning 161
compartment syndrome 281
compressive stocking 217
congenital aneurysm 23
congenital lymphangiectasia 240
congenital lymphedema 235
continuous-wave Doppler probe 60

contrast venography 73
contrast-enhanced CT complements aortography 118
contusion 277
conventional arteriography 74
costoclavicular syndrome 21
cough impulse test 29
cramping pain 15
CRCT syndrome 111
crescendo TIAs 94
CT scan 62
cuffed dialysis catheter 264
curved upper arm graft 266
cutaneous angiomata 32
cystic lymphangioma 236
D
Dacron grafts 83
DeBakeys maneuver 116
declamping hypotension 120
decompressive fasciotomy 283
deep lymphatic systems 233
deep space infection 199, 201
deep thrombophlebitis 226
deep vein thrombosis 26
deep venous thrombosis (DVT) 223
delayed nerve ischemia 287
demarcation 171
dermal plexus 233
Dextran 44, 229
dialysis access grafts 266
dialysis catheter 263
diethylcarbamazine 238
digital subtraction angiography 74
Dipyridamole 44
dipyridamole 138
dipyridamole-Thallium scintigraphy 88
direct single-lumen percutaneous puncture 263
disabling claudication 159
Dobutamine stress echocardiography 88
Doppler survey 63
Doppler ultrasonography 226
double velour Dacron graft 83
duplex scanner 224
duplex ultrasonography 74
duplex venous ultrasonography 69
309
early graft failure 250

echocardio-graphy (2-dimension) 180
echocardiography and radionuclideventriculograph 88
ejection fraction 88
EKG monitoring (24-hr) 132
electrographic monitoring 88
embolism 22
endoscopic subfascial ligation 209, 217
endothelial seeding grafts 84
endovascular stent grafting 119
endovascular therapy 78
ER thoracotomy 123
erythrocyte sedimentation rate (ESR) 174
essential hypertension 150
ex-vivo reconstruction 155
excisinal procedures 239
exercise testing 64
exercised ABI 137
expanding pseudoaneurysm 277
expansile pulsation 116
extra-anatomic surgical procedure 132
extra-anatomical renal artery revascularization 155
gaiter area 29
gangrene 17
Giacomini vein 216
giant cell arteritis 112
glycolytic pathway 200
gouty arthritis 202
graft failure 89
guillotine amputation 291
guttering of the veins 11
F
failing graft 250
fasciotomy 185, 281
Fegans method 30
femoro-femoral crossover bypass 132
femoro-popliteal occlusive disease 159
femorofemoral bypass graft 132
fibrinolytic agents 49
fibrinolytic therapy 185
fibrointimal hyperplasia 82
fibromuscular dysplasia 149
fistula and graft maturation 269
fistulography 270
flare sign 29
Fogarty balloon catheter 256
Fogerty balloon tip catheter 184
Fontaine stepwise classfication 168
foot claudication 168
fore-arm arteriovenous fistula 266
fore-arm loop graft 266
free root 169
fungus vegetations 189
H
hard signs 278
Harveys test 31
hemodialysis access 261
hemorrheologic drugs 47
heparin 147
heparin-induced-thrombo cytopenia 45
heparin-induced-thrombocytopenia (HIT) 147, 227
high velocity missle 275
highflow AVF 270
highly selective catheterization 72
Homans sign 26, 223
human umbilical vein grafts 82
Hunters canal 38, 159
hyperkeratosis 33, 236
hypothenar hammer syndrome 107
I
I125-labelled fibrinogen uptake test 225
ICU psychosis 249
idiopathic Raynauds disease 22
immediate postoperative prostheses (IPOP) 296
impedance plethysmography 224
impedence plethysmography 62
implanted graft 263
impregnated autoclave Dacron graft 83
impregnated Dacron graft 120
in situ interposition aortic graft 195
in situ saphenous vein bypass 82
incompetent perforators 209
indium-111-labeled white blood cell scanning 194
infected false aneurysm 190
inferior inguinal nodes 233
inflammatory AAA 118
intermittent claudication 15
intermittent claudication (IC) 137
intermittent pneumatic calf compression 229
310
intermittent posterior cerebral ischemia 95
interventional radiology 8
intimal disruption 275, 277
intimal hyperplasia 40
intra arterial digital subtraction arteriography 74
intraluminal AAA 119
intraluminal Greenfield filter 227
intraluminal shunt 281
intraluminal vascular prostheses 78
intraoperative arteriography 281
inverted champagne bottle 28
iodine starch test 301
ischemic demarcation 182
ischemic rest pain 17
ischemic ulcer 17
ischemic waste products 183
IVC plication 6
Ivermectin 238
J
juxtaglomerular apparatus 150
K
Klippel-Trenaunay syndrome 32
L
laser angioplasty 77
lateral venorrhaphy 260
lateralizing trasient ischemic attack (TIA) 93
Leriches syndrome 20, 127
limb-threatening ischemia 159
livedo reticularis 22, 109
ooped upper arm graft 268
low melecular weight heparin 45
low molecular weight dextran 249
low molecular weight heparin 229
low-dose heparin 227
lumbar sympathectomy 6
lumbar sympathetic trunk 299
lymphadenopathy 34
lymphangiography 233
lymphangioma 34
lymphangioma simplex 236
lymphangiosarcoma 236
lymphangitis 32
lymphatic grafting 240
lymphatic reconstruction 239, 240
lymphedema 32, 33, 235
lymphedema praecox 236

lymphedema tarda 236
lymphocele 243
lymphovenous anastomosis 240
M
magnetic resonance angiography 62
magnetic resonance arteriography 118
magnetic resonance arteriography (MRA) 161
magnetic resonance flowmeter 62
magnetic resonance imaging 62, 74
magnetic resonance techniques 62
malignant hypertension 149
Mandors disease 27
manual lymphatic drainage (MLD) 239
Marjolins ulcer 29
MAST-G-SUIT 282
mechanical reduction 239
mechanical retractor 145
medium-chain triglyceride 242
megalymphatics 240
microangiopathy 200
microbial arteritis 190
Milroys disease 236
Mobile Army Surgical Hospital (MASH units) 4
Modified Homans procedure 240
multilobulated aneurysm 194
multiple organ failure 179
mycotic aneurysms 189
myoglobinuria 180
N
Naftidrofuryl 139
necrotizing fascitis 201
nephrectomy 155
neurologic deficit 20
neurotrophic ulcer 19, 202
neurotropic ulcer 159
non-cuffed dual-lumen dialysis catheters 263
non-pitting edema 236
noninvasive hemodynamic studies 59
noninvasive tests 59
nonspecific arteriopathy 115
O
ocular plethysmography 61
Omni retractor 147
open amputation 291
311
penile/brachial pressure index 65

Pentoxifylline 47, 140
percutaneous arterial catheterization 4
percutaneous transluminal angioplasty 75, 132
percutaneous transluminal angioplasty (PTA) 153
perianastomotic neointimal hyperplasia 270
peritoneal-venous shunt (Lee Veen) 242
Perthes test 210
Peu d Orange appearance 235
Phantom limb pain 296
Phantom limb sign 17
phlebitis migranes 168
phleborheography 62
phlegmasia alba dolens 26
phlegmasia alba Dolens (PAD) 227
Phlegmasia Cerulea Dolens 227
phlegmasia cerulea dolens 26
plantar compartment 199
plantar foot pad 199
polycythemia 180
polytetrafluoroethylene (PTFE) graft 121, 263
port wine stains 32
portable Doppler unit 59
positron emission tomography 74, 96
postmastectomy edema 34
postmastectomy lymphedema 237
postsympathectomy neuralgia 304
postthrombotic syndrome 226
Praxilene 139
pre-clotting Dacron graft 120
pregangrene 17
presenile spontaneous gangrene 167
primary chylous disorders 240
primary livedo reticularis 22
primary lymphedema 235, 236
primary Raynauds disease 22
primary vascular infection 55
progressive distal axonopathy 200
prophylatic fasciotomy 283
prostaglandin 45, 139
protamine 185
pseudoaneurysm 271
pulmonary embolism 26, 221
pulmonary embolism (PE) 226
pulmonary hypertension 173
pulse volume recorder 60, 61
pulse volume recordings 64
pulsed-wave Doppler flow detector 60
radicularis artery 122

Ray amputation 292
Raynaud's phenomenon 21
Raynauds disease 109
Raynauds phenomenon 22, 109
reactive hyperemia test 15, 64
recurrent carotid stenosis 104
recurrent DVT 226
recurrent superficial thrombophlebitis 168
renin -angiotensin -aldosterone system 150
renin dependent hypertension 150
renin determination 152
reperfusion syndrome 179
retroperitoneal approach 121
reversible ischemic neurologic dificit (RIND) 94
Robertsons giant limb 32
robot retractors 145
ruptured abdominal aneurysm (AAA) 122
S
saccular aneurysm 120, 194
saphenous nerve 216
saphenous vein in-situ technique 164
secondary chylous disorders 242
secondary livedo reticularis 22
secondary lymphedema 235
segmental leg pressure 63
Seldinger technique 72
self-retaining retractor 143
sequential air compression 239
severe claudication 159
severe crush injury 291
shot gun wounds 275
single position emission computed tomography 96
single shot arteriography 279
single-armed robot retractor 147
Smithwick test 301
soft signs 278
soleus sinusoids 221
sorbital pathway 200
spastic paralysis 299
spiral CT scaning 118
stab avulsions 216
steal phenomenon 138
steal syndrome 269
Stemners sign 235
straight fore-arm graft 266
streptokinase 77, 186
312
string phlebitis 27
stripping of the short saphenous vein 216
stroke 94
stump pressure 102
subclavian steal syndrome 21, 94, 95
subcutaneous removal of varicostics 216
subfascial ligation of perforating veins 217
Sudan fat stain 242
Sulotidyl 139
superficial thrombophlebitis 26
superficial venous thrombosis 223
superior inguinal nodes 233
suppurative thrombophlebitis 226
sural nerve 216
syme amputation 7
Symes amputation 294
sympathectomy 171, 287, 299
sympathetic block 287
sympathetic regeneration 304
T
Takayasus arteritis 112, 173
temporal arteritis 112
Thompsons procedure 240
thoracic outlet syndrome (TOS) 107
threatened limb loss 127
thromboangiitis obliterans (TAO) 167
thromboangitis obliteran 20
thromboendarterectomy 155
thrombophebitis migrans 27
thrombophlebitis 226
Ticlopidine 139
tissue plasminogen activator 77
toe ampulation 292
toe pressure 65
tolazoline 281
Torniquet test 30
tortuous aorta 116
transcranial Doppler 67
transcranial Doppler studies 98
transcutaneous oximetry 62
transection 278
transient cerebral ischemia 93
transient ischemic attack 20
transient monocular blindness 93
transient neurologic deficit 20
translumbar aortic puncture 4
transmetatarsal amputation 7, 293
transmitted pulse 116

transmural necrosis 173
transposed vein arteriovenous fistula 265
trash foot 122
Trendelenberg test 29
U
ultrasound 73
ultrasound B-mode 62
upper arm graft 266
urokinase 77, 186
V
valvular incompetence 221
varicose veins 29, 209
vascular access 261
vascular angle 9
vasodilators 48
venogram 225
venous autografts 81
venous filling 11
venous gangrene 26, 229
venous hypertension 27, 264
venous plethysmography 60, 68
venous stars 25
venous stasis ulcer 28
venous thrombosis 221
venous ulcers 209
vertebrobasilar insufficiency 20, 94
vibratory white finger 107
Vietnam Vascular Registry 4
Virchows triad 223
volume-dependent hypertension 150
W
W. bencrofti 238
Warfarin 227, 229
Woven Dacron graft 120
wrist fistula 264
X
xenografts 82
Y
Yellow Nail Syndrome (YNS) 237
lymphangioma simplex 236

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VASCULAR SURGERY

10 Cerebrovascular disease ................................................................................................................... 93

23 Surgical Treatment of Vericose Veins ....................................................................................... 209

Robert Matas (.. 1888-1940)

Occlusive and aneurysmal lesions

Vinyon-N Voorhees .. 1949(12,13)

The bypass principle

Aortic Aneurysm Resection

aneurysmorrhaphy cellophane electro coagulation .. 1951 Rene

underlying critically ill

Vascular access for dialysis

.. 1934 Homan IVC ligation

Ligation and stripping of

eral vasospasm occlusive disease

The American Board of

noninvasive diagnotic procedures

William Edward Jr. endovascular grafting

1. Dale WA. The beginnings of vascular surgery. Surgery 1974;76:84956.

7. Ewards WS, Edward PD. Alexis Carrel: Visionary Surgeon. Charles

15-30o vascular angle 20o

5. abdominal aortic aneurysm (AAA)

Capillary filling time vascular angle

2.1 vascular angle Buergers angle

2.2 Buergers test

2.4 pressure area

Dorsalis pedis pulse

Allen test radial ulnar artery

Reactive hyperemia test

2.1 INTERMITTENT CLAUDICATION (IC)

2.2 ISCHEMIC REST PAIN

(vascular angle) 20o

2.3 PREGANGRENE AND GANGRENE

2.10 ischemic rest pain

2.4 ISCHEMIC ULCERATION

2.3 ISCHEMIC ULCERATION

2.5 NEUROPATHIC ULCERATION

2. spina bifida, tabes

2.6 OCCLUSIVE PERIPHERAL VASCULAR

2.6.8 CERVICAL RIB SYNDROME 0.4%

2.6.9 RAYNAUDS PHENOMENON

primary livedo reticularis

2.7 ACUTE ARTERIAL OCCLUSION

2.7.1 ACUTE ARTERIAL THROMBOSIS

2.8 ANEURYSMAL DISEASE

Congenital : weak areas (berry aneurysm)

congenital arteriovenous fistula

Infection: non-specific bacterial

2.13 De Bakeys sign AAA

abdominal aortic aneurysm (AAA)

2.15 competency saphenous vein

2.16 venous ulcers brawny induration

1.1 ACUTE VENOUS THROMBOSIS

2.10 superficial thrombophlebitis

1.1.4 Thrombophebitis migrans

1.2 CHRONIC VENOUS INSUFFICIENCY

Bleeding with manipulation

Lower 1/3 of leg

Always but may

long short saphenous veins

2.17 perforating veins

incompetent saphenofemoral valve

2.19 Brodie-Trendelenberg test

2.20 Torniquet test