Out of the frying pan & into the fire Dr Duncan Anderson Vascular Surgeon www.drduncananderson.co.za
The frying pan • Traditionally the surgeon has been based in the operating theatre • Preoperative angiography was routinely performed by the radiologist
Case 1: Critical limb ischaemia • 61 year old male • Non-healing left ankle ulcer for 9 months • Risk factors: heavy smoker, hypertension & hypercholestrolaemia • Only left femoral pulse • Ankle brachial index: 0.46
Case 1: Critical limb ischaemia • Catheter directed angiogram in the cathlab • Left femorodistal bypass to the posterior tibial artery • Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein
Case 1: Critical limb ischaemia • Who should be referred to a vascular surgeon? • And which special investigations should be performed prior to referral?
Who should be referred? â&#x20AC;˘ Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene â&#x20AC;˘ All patients with ankle brachial index <0.9 â&#x20AC;˘ Any diabetic, chronic renal failure patient or heavy smoker with absent pedal pulses
Which special investigation? • Ankle brachial index (ABI) only – ABI 1.3-0.9 manage vascular risk factors – ABI 1.3-0.9 safely apply compression bandaging for venous stasis ulceration
• • • •
No arterial duplex doppler ultrasound No CT angiography No MR angiography No cathlab angiography
The fire • Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography • Cathlab • Hybrid theatre • Offers a more goal directed therapy
Case 2: Complex varicose veins • 36 year old female • Recurrent bilateral varicose veins • Vein surgery in 2005 • Pelvic congestion syndrome – Menorrhagia – Dyspareunia – Dysmenorrhoea
Case 2: • Suspect pelvic /ovarian vein reflux – Recurrent varicose veins – Atypical varicose veins – Extensive groin varicosities – Vulvae varicosities – Pelvic congestion syndrome
Case 2: Complex varicose veins • CT venography • Not a routine special investigation (timing critical) • Catheter directed venography
Case 2: Complex varicose veins • Traditionally vein ligation & stripping • Endovenous laser or radiofrequency (VNUS) ablation – – – –
No groin wound No thigh bruising Less postoperative pain Earlier mobilization
VNUS ablation • Radiofrequency ablation • Cathlab or rooms • Ultrasound-guided • Tumescence infiltration • Immediate ambulation
VNUS ablation • Tumescence infiltration – Local anaesthesia – Facilitates ablation by vein compression – Reduces risk of deep vein thrombosis – Creates “heat sink” to protect surrounding tissue
VNUS ablation â&#x20AC;˘ Less pain & less bruising than laser ablation â&#x20AC;˘ Who should be referred to a vascular surgeon?
Who should be referred? • Atypical distribution of varicose veins • Recurrent varicose vein • Associated chronic venous insufficiency (venous stasis dermatitis or venous ulcer) • Suspicion of pelvic/ovarian vein reflux • VNUS ablation for better cosmetic result, less pain & immediate mobilization
Case 3: False aneurysm • 49 year old female • Painful swelling right groin 2 weeks after cathlab • BMI 40.4 • Large false aneurysm flush with common femoral artery (no neck)
Case 3: False aneurysm • Direct surgical approach • Burst on skin incision • Direct digital control of 2cm defect in common femoral artery • Total of 4 unit blood transfusion
Case 3: False aneurysm • Proximal control digitally through pelvis • Repaired with vein patch • Discharged after 6 days • High risk of wound & graft sepsis
Case 3: False aneurysm • Negative surgical aspects – Additional open surgical procedure – Risk of anaesthesia – Prolonged hospital stay – Postoperative pain – High risk of wound & graft sepsis – Difficult mobilization
Case 4: False aneurysm • 74 year old female • Painful right groin swelling 1 day after cathlab • BMI 32.2 • Dropped haemoglobin from 13g% to 9g%
Case 4: False aneurysm • Long & narrow neck • Ultrasound-guided thrombin injection
Case 4: False aneurysm
Case 4: False aneurysm • Angioplasty balloon to arrest flow within aneurysm • Thrombin (factor IIa) converts fibrinogen to fibrin • Discharged within 48hrs
“If all that you have is a hammer, then all that you’ll see are nails”
UROLOGIST
VASCULAR SURGEON
ANAESTHETIST