sihotský v., frankovičová m. kubikova m. 4.gm... · duplex sonography ... pelvic veins ......
TRANSCRIPT
Sihotský V., Frankovičová M. Kubikova M.
Klinika cievnej chirurgie LF UPJŠ a VÚSCH a.s.
Imagine methods in vascular
medicine
Sonography
Doppler
Triplex
CT-Angiography
MR-Angiography
MRI angiography
Angiography (AG)
Angiography - gold standard !!! DSA
Advantages
○ good resolution
○ possibility of intervetion
○ retreat from AG as a diagnostic
Disadvantages
○ invasive - possible damage - PSA and others
○ contraindications
Iodine allergy
renal insufficiency
Angiography (occlusion of common illiac arteries
Endovascular treatment
Conservative treatment
Endovascular treatment
Surgical treatment
Endovascular treatment Indication
Better for shorter, isolated stenosis
The larger the vessel, the better the throughput
TASC (Transatlantic InterSociety Consensus)
PTA and event. Stent
Pictures:
1.Angiography- stenosis of left common
illiac artery
2. Balloon angioplasty of left common
illiac artery
3. The result of intervention – restored
blood flow
Endovascular treatment Stents coated with vascular
prosthesis - stent grafts,
For treatment of aneurysms or bleeding
They do not leak blood
Endovaskular trombolysis
Arterial
Periferal arteries
Venous
phlebotrombosis
Bypass, central venous cathether, A-V
(arteriovenous) fistula
Before thrombolysis
After thrombolysis
Surgical treatment
Embolectomy: removing the embolus from the vessel using a using a balloon catheter (Fogarthy)
Surgical treatment
Endarterectomy and patch angioplasty
Surgical treatment
Resection and implantation
of interpositum (prosthetic,
venous...)
Bypass
Forms
Anatomical
Extraanatomical
Substitution (possibilities)
GSM (great saphenous vein)
Proshesis
Donor GSM
Acute limb ischemia
Akcute limb ischemia (ALI): is a
sudden drop in limb perfusion that
compromises its vitality. It requires
urgent revascularization..
Etiology
Embolia
Thrombosis
Trauma
5 P
Pain Bolesť
Pulslessness Nehmatný pulz
Paleness Bledosť
Paresthesia Parestézia
Paralysis Porucha hybnosti
Cold
Classification Rutherford I. extremity is viable
No sensitive and no motoric deficit
Conserative treatment
II. the extremity is threatened a requires revascularization
A sensitive deficit is present – may be endovascular treatment,
treatment may be delayed
B sensitive and motoric deficit is present- requires surgical
revascularization - can not be delayed
Venous flow is present (maintained)
Irreverzible ischemia
III. The limb is irreversibly damaged and cannot be saved.
Amputation required.
Irreverzible limb changes
Absence of venous flow !!!
Imagine methods
Diagnosis
Ultrasionography
CT-AG (angiography)
DSA (Digital substraction agiography)
Acute arterial occlusions
Treatment:
I. conservative.
IIa endovascular:
○ Trombolysis, aspiration..
IIb surgical:
○ Trombectomy, bypass
III. amputation
Acute arterial occlusions
Complications
Revascularization syndrome
○ Multi - organové failure
○ Exitus
Compartment sy
Finding the causes and treatment
Arterial injury Sharp injuries
Dominates bleeding !!!!!
Patient immediately at risk of hemorrhagic shock
Urgent surgical revision without imaging methods
Blunt injuries
Dominates ischemy !!!!
Necessary verification by imaging methods
It may be overlooked especially for other associated injuries !!!!!
Associated injuries
Diagnosis
Symptoms, clinic Bleeding
Disappeared pulsations (missing puls.) !!!!!!
Doppler – indicatively The normal curve is triphasic
There may be a continuous flow behind the cap
Duplex sonography
CT-Angiography (CTA)
DSA (digital subtraction angiography)
Treatment
Conservative Small intimal flaps non-closing lumen
Small pseudoaneurysms (lless than 2cm)
Neither ischemia nor extravasation is present
Endovascular treatment Bleeding, occlusion
More with blunt injuries
Advantageous for less accessible vessels ○ Subclavian, iliac, aorta
Surgical treatment
Direct suture
Avoid the
narrowing of the
blood vessel
Suture with patch
Safer
Direct end to end anastomosis In transversal laesions
sometimes reccomended
We don´t do it
Interpozitum At our workplace always in
transversal lesion
Vein – GSM
proshesis
Bypass Especially in blunt injuries
With ligation of damaged artery between anastomoses
Graft
Autologus vein GSV(grand saphenous vein)
Rezistant to low virulent infection
Convenient for reconstructing small caliber arteries
Proshesis Faster construction
No time wasting GSM collection
Upper extremity
Axilar and brachial artery Always necessary the arterial reconstruction
The nervus medianus is frequently injured
Upper extremity
Radialis and ulnaris
artery If only one of the arteries of the forearm
is injured and the Allen test shows a
passable palmar arch, the injury can be
safely ligated
If both arteries are injured, preference
is given to reconstruction of the ulnar
artery
In our workplace, we also reconstruct
the isolated injury of the forearm
artery and in case of injury of both
arteries, we reconstruct both of them
David S Kauvar, Vascular trauma: Extremity in Rutherford´s Vascular
Surgery, 8th edition, 2014
Femoral arteries AFC (arteria femoralis communis) necessary reconstruction
AFS (arteria femoralis superfitialis) the artery most commonly injured ○ necessary reconstruction
AFP (arteria femoralis profunda) it should be reconstructed ○ It is important collateral vessel
○ It may be ligated in an unstable patient
Femoral artery injury mortality is nearly 10
Popliteal artery
After AFS the second most frequently injured artery of the
lower extremity
60% blunt injuries
60-70% fracture present
20% injuty of the popliteal vein
Highest amputation rate 27%
Medial approach above and below the knee Belly position less preferred
Interpositum or bypass treatmenti
Crural arteries
50% blunt injuries
An isolated injury of a single crural artery
may be ligated
For injuries to multiple crural arteries, at
least reconstruction of one of them is
required
Poor access, reconstruction via interpositum
Venous reconstructions
The results are questionable
45%-100% of venous reconstructions are strombotized in the first days
This thrombosis may be transient
Reconstruction of the vein If the patient's condition and local conditions allow it
Certainly VFC (vena femoralis communis)
Compartment sy
Lower extremities 40% patients after revascularization require fasciotomy.
Fasciotomy concomitantly or immediately after surgery reduces the risk of amputation by 4-fold !!!
We perform fasciotomy on the lower limbs after reconstruction always !!!!!!
Upper extremities
20% of patients after brachial artery reconstruction have compartment sy
Amputations Ranging from 7-30%
The most frequent localisastion Upper extremities : forearm
Lower extremities: popliteal artery
Up to 2 times more often for blunt injuries
The presence of multiple fractures and soft tissue injury increases the risk 2-3 times
Concomitant fasciotomy reduces the risk of amputation by 4-fold
Intrathoracal and intraabdominal
arteries
Massive bleeding
Few patients survive transport
Urgent revision
Dissection – stentgraft
Stentgraft
Stenosis ACI (arteria carotis interna)
USG, CT-AG, DSA
Surgery – prevention of another stroke
Indication Above 70% in asymptomat.
Above 50% in sympt. Within 14 days of stroke
Contraindication Occlusion of ACI, stroke in
progression , intracranial pathology, pure prognosis
Acute occlusion of ACI
Revascularistion revascularization within 6 h of onset of symptoms
Brain CT to exclude intracranial haemorrhage
Due to the short time window, these were mostly patients hospitalized in neurological workplaces
AAA
Anerysma aortae abdominalis
Etiol- Atherosclerosis
Clinic Asymptomatic
Symptomatic
○ Pain
○ Embolisation
Rupture
Diagnosis: sonography, CTA, MRI Echocardiography,Transesophageal
echocardiography, thoracic aneurysm
Therapy- AAA
Indication more than 5,5 cm, all circumstances need to be considered
5-6cm 3-15%(1 year mortality)
7-8cm 20-40%
Therapy
Interpositum
Bifurcated prosthesis Einstein
Rupture-AAA
Clinic:
pain
Pulsating resistance
Shock
Dg: sonography, CT
Th: urg. surgery, stentgraft
Poor prognosis
50% does not survive transport
50% does not survive surgery
CT- rupture AAA
Predoperative procedure
Patients with systolic blood pressure of 50-70 mmHg survive
better
Infusions of more than 3.5 l before surgery resulted in a
3.54-fold increase in the risk of death Hardman DT, Ruptured abdominal aortic aneurysms, J Vasc Surg 1996
Those who get alive to the hospital are usually
stable 87% survive more than 2h, therefore most patients are
sufficiently stable to perform CT-AG !!!
Surgery without CT-AG !!! Exmination: In unstable patients with suspected AAA or usg verified AAA,
where CT-AG would lead to possession
In unstable patients, mortality increases by 1% with each
minute
Algorithm
Suspection R(ruptured)AAA
CT-AG
USG
AAA
stable
instable
Urgent
surgery
AAA
without
rupture
Elective
surgery OP
to 48h !!!
negat Another
cause
Types of aneurysms
Stentgraft
Acute occlusion a. mesenterica
superior In atrial fibrillation
Sudden abdominal pain Paralysis, vascular ileus
Finding on the abdomen non-specific Blood in stool
Dg CT-AG !!!!
Therapy
Embolectomy AMS arteria
mesenterica superior
Reversible ischemia may occur within 6-12 hours.
Intestinal resection Extensive
ileotransversoanastomosis
Second look operations Within 24h
Trombophlebitis- superfitial vein
inflammation
Ethiology Aseptic form ( paravenous application and
infusion )
Septic
Stiff painful streak, minimal edema of the surrounding tissues
Heparin ung, and local compression, ATB, ANP, mobilisation,
For severe forms- LWMH (low mollecular
heparine)
Migratory - possible malignancy
PHLEBOTROMBOSIS
Closure of deep venous system
Ethiology: Wirchov trias Hypercoagulable state
Endothelial damage
Thrombus formation Retraction of thrombi 7-12 days
Organization and recanalization of the thrombus
Phlebotrombosis
Localisation
Calf
Thigh
Pelvic veins
Upper extremities
Clinic
Asympthomatic
Pain
Calf oedema
Pretibial veins
Differentiation in the circuit of extremity
Homans, plantar sign
Dg-phlebotrombosismbózy
USG of deep venous
system
D-dimers
Phlebography
Therapy
LWMH 2x 0.1ml per 10kg - possibly outpatient treatment
Heparinisation 30000j continuously i.v to to 2-3 times aPTT + imobilisation
Intravascular trombolysis – tissue activator of plasminogen
Antikoagulant therapy for 3-12 months - angiologists
Thrombolysis
Complications
Pulmonar embolisation
Arterial blood flow failure
Postthrombotic syndroma
Further investigation
Hematologic – hyperkoaguable status
Oncology screening USG of abdomen, X-ray of the chest
Markers
Urology
Long term Bandage, drinking regime, venotonics
ANP, Clopidogrel, Vessel due, LWMH, Kumarins, NOAK
Prevention
Elastic stocks, bandage
Early RHB, breathing exercises
LWMH !!!!!
Kaval filters
In high - risk patients
OK