Vascular Surgery
Lec : 2
Aneurysmal diseases:
Aneurysm :-
means dilatation of localized segment of the arterial system, classified :-
1. according to wall thickness
a. True An. :-contain the 3 layers of the arterial wall (intima ,media ,adventitia ) in
the wall of An. Sac.
b. False An. :- in which single layer of fibrous tissue formthe wall of An. Sac e.g
Traumatic An.
2. according to Shape :- a.Fusiform b. Saccular c. Dissecting.
3. according to Etiology :- a. Atheromatus b. Collagenous c.Infective d.Traumatic
An. Can occur any where in the major vessels , the majority are true , fusiform and
atheromatus.
C.F :- Symtoms are related to :- 1.vessel affected
2. Tissue or organ which the artery supply.
Symtoms occur due to :- 1.Expansion 2.Thrombosis 3.rupture 4.Embolization.
O/E :- Significant size An. Can be felt as an expensile pulsation.
Abdominal Aortic Aneurysm:-
Is the most common type of large vessel An.,it mostly involve the Aorta below
Renal arteries. It may be presented as :-
1.Ruptured An. :-
rupture occur 80% anteriorly leading to free bleeding into
peritoneal cavity , it assocciat with high mortality.
20% rupture occur posterolateral into retroperitoneal space and produce
Retroperitoneal hematoma , here hypotension and resistance of retroperitoneal
space will arrest bleeding.
Overall 60% of pt.s die at onset of rupture while 40% can reach hospital.
C .Fs :- Pt. present with sever abdominal and/or back pain , shock
Dx:- tender pulsatile mass is palpaple in abdominal of hypotensive pt. , dx is done on
clinical findings and must be rapid and there is no time for imaging study.
Mx :- must be quick
1. insert 2 I.V lines one of them must be inserted at large centeral vein.
2. start I.V fluid to keep SBP about 100 mmHg to keep cardiac perfusion
and prevent rebleeding
3. Rapid transet to operative room for surgery with 6 pints blood
preparation.
2. Symtomatic An. :A
. Pt. present with abdominal and/or back pain.
B. Pressure of An. On adjacent structure produce compression symtoms
on GIT , urinary system , Lower limb nerves and venous system.
In symtomatic Pt.s surgery indicated regardless to size of An. Since 80% will die
with in 1 year if they are not operated.
Asymtomatic An. :- found incidentally on examination or during
radiological assessment , surgery is indicated in :-
1. :- An > 55mm in anteroposterior diameter and the Pt. must be fit for
surgery.
Investigation :- 1.complete blood picture , Liver function tests ,
coagulation studies , Lipid profile , renal FTs
2. prepare fresh blood
3.assess cardiorepiratory function by ECG , Echo , Pulmonary FTs
4. CT scan abdomenthe size of An. As the conventional angio cannot
show the real diameter of An. As it is filled with clots which leads to false
narrow angio appearance
Operative method :- 1. Under G.A , pt. is supine , full mid-line abdominal
incision , small intestine lifted to the right , posterior peritoneum opened
2. upper and lower limits of An. Identified , I.V heparin given , and cross
clamp put above and below An. Sac , An. Opened and clots evacuated.
3.prosthetic graft is sutuered end to end to the Aorta inside the An.sac
which is closed over the graft later , clamps released slowly.
Endoluminal prosthesis :- suitable for elderly pt. who are unfit
supermajor surgery.
1. Both common femoral arteries are exposed surgically under screen
control.
2.delivary system guided up into Aorta and endovascular prosthesis
placed within Aortic sac to ensure firm attachment to vessel above and
below An. Sac.
Popliteal artery An.:-
represent 70% of peripheral An. , 65% are
bilateral , 35% associate with abdominal An. , pt. present with swelling
behind knee , distal ischemia may occur due tothrombosis or distal
embolization.
Dx :- by Dopplar study , CT angio
Surgery indicted for :- 1.symtomatic An.
2.Asymtomatic An.> 25mm in diameter.
Methods of surgery :- 1. Resect and put inlay graft.
2.ligate An. Proximally and distally and put bypass graft.
Arterio-Venous Fistula(AVF) :-
means communication between
artery and vein which may be 1.Congenital 2.Traumatic
3.Iatrogenic AVF for hemodialysis , AVF leads to :-
1.structural effect :- when arterial blood flow to vein , the vein wall will
become arterialized i.e dilated , tortuous , thick wall
2.physiological effect:-if AVF is big enough it will increase cardiac
outputwhich may leads to LV enlargement and heart failure.
O/E :- 1.pulsatile swelling when the lesion is superficial.
2. thrill on palpation 3.dilated veins
4. Buzzing continous bruit( machinery murmur) on auscultation
5. compressing of artery proximal to fistula will decrease swelling and
bruit
Dx :- by dopplar , angiography.
Mx :- 1.Embolisation of the site of AV communication for congenital AVF
since it has multiple communication.
2.for Traumatic AVF excision of the AV communication and arterial
continuity established byinterposition graft.
3.for Iatrogenic AVF quadruple ligation of artery and vein proximal and
distal to AVF.
Thromboangiitis Obliterans (Burger disease):-
Characterized by segmental occlusion of medium size arteries ,
mostly involve leg but forearm also may be involved , it may be
associated with thrombophlibitis of superficial or deep deep veins and
Raynauds syndrome , it occur in male , smoker , age < 30 yr.
Histologically- there is segmental inflammatory changes in the wall of
the artery with thrombotic obstruction which is hard and white in color
and the arterial wall in between the involved segment is normal.
Rx :- 1. Stop smoking completely 2.Asprin
3.arterial dilator e.g deltiazim .
4.Sympathectomy , arterial bypass procedure are of little value.
Gangrene :-
death of macroscopic part of tissue usually affect distal
part of limb dueto arterial obstruction , usually of 2 kinds
1.Dry Gan. :- develop due to gradual slowing of blood flowfrom
atheroseclerotic disease , the affected part become dry and wrinkled
with black discolorationdue to Hb disentigration and greasy to touch.
2. Moist Gan. :- occur when infection and putrefaction are present , the
affected part become swallon and discolored and epidermis may be
raised in blebs , creptus may be present due to gas forming micro-
organism.
Seperation of gangrene :- demarcation zone develop between viable
and dead part as a layer of granulation tissue , the line of separation will
be more proximal in moist Gan. Than in dry Gan. , therefore ; dry Gan.
Must be kept dry and attempt made to convert moist Gan. To dry .
Rx :- 1.improve blood supply of proximal part to make amputation as
distal as possible
2.keep the affected part dry and exposed to air.
3.use air beds to avoid local pressuer area
4.remove hard desiccated skin helps demarcation , release of pus and
relieve of pain.