Surgery_Schwartz

Surgery_Schwartz. Ann Thorac Surg. 1999;67(6):1609-1615. 221. Melina G, De Robertis F, Gaer JA, et al. Mid-term pattern of survival, hemodynamic performance and rate of complica-tions after Medtronic Freestyle versus homograft full aortic root replacement: results from a prospective randomized trial. J Heart Valve Dis. 2004;13(6):972-975. 222. Badiu CC, Eichinger W, Bleiziffer S, et al. Should root replacement with aortic valve-sparing be offered to patients with bicuspid valves or severe aortic regurgitation? Eur J Car-diothorac Surg. 2010;38(5):515-522. 223. David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Car-diovasc Surg. 2010;140(6 suppl):S14-S19. 224. Zingone B, Gatti G, Spina A, et al. Current role and outcomes of ascending aortic replacement for severe nonaneurysmal aor-tic atherosclerosis. Ann Thorac Surg. 2010;89(2):429-434. 225. Achneck HE, Rizzo JA, Tranquilli M, Elefteriades JA. Safety of thoracic aortic surgery in the present


Surgery_Schwartz

Surgery_Schwartz. for severe nonaneurysmal aor-tic atherosclerosis. Ann Thorac Surg. 2010;89(2):429-434. 225. Achneck HE, Rizzo JA, Tranquilli M, Elefteriades JA. Safety of thoracic aortic surgery in the present era. Ann Thorac Surg. 2007;84(4):1180-1185. 226. Estrera AL, Miller CC, III, Madisetty J, et al. Ascending and transverse aortic arch repair: the impact of glomerular filtra-tion rate on mortality. Ann Surg. 2008;247(3):524-529. 227. Fleck TM, Czerny M, Hutschala D, et al. The inci-dence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest. Ann Thorac Surg. 2003;76(4):1198-1202. 228. Immer FF, Barmettler H, Berdat PA, et al. Effects of deep hypo-thermic circulatory arrest on outcome after resection of ascend-ing aortic aneurysm. Ann Thorac Surg. 2002;74(2):422-425. 229. Heinemann MK, Buehner B, Jurmann MJ, Borst HG. Use of the “elephant trunk technique” in aortic surgery. Ann Thorac Surg. 1995;60(1):2-6. 230. LeMaire SA, Carter SA, Coselli JS. The


Surgery_Schwartz

Surgery_Schwartz. MK, Buehner B, Jurmann MJ, Borst HG. Use of the “elephant trunk technique” in aortic surgery. Ann Thorac Surg. 1995;60(1):2-6. 230. LeMaire SA, Carter SA, Coselli JS. The elephant trunk tech-nique for staged repair of complex aneurysms of the entire thoracic aorta. Ann Thorac Surg. 2006;81(5):1561-1569. 231. Safi HJ, Miller CC, III, Estrera AL, et al. Staged repair of extensive aortic aneurysms: long-term experience with the elephant trunk technique. Ann Surg. 2004;240(4):677-684. 232. Sundt TM, Moon MR, DeOliviera N, et al. Contempo-rary results of total aortic arch replacement. J Card Surg. 2004;19(3):235-239. 233. Svensson LG, Kim KH, Blackstone EH, et al. Elephant trunk procedure: newer indications and uses. Ann Thorac Surg. 2004;78(1):109-116. 234. Kazui T, Yamashita K, Washiyama N, et al. Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg. 2007;83(2):S796-798. 235. Bischoff MS, Brenner RM, Scheumann J, et al. Long-term outcome after aortic arch


Surgery_Schwartz

Surgery_Schwartz. N, et al. Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg. 2007;83(2):S796-798. 235. Bischoff MS, Brenner RM, Scheumann J, et al. Long-term outcome after aortic arch replacement with a trifurcated graft. J Thorac Cardiovasc Surg. 2010;140(6 suppl):S71-S76. 236. Iba Y, Minatoya K, Matsuda H, et al. Contemporary open aortic arch repair with selective cerebral perfusion in the era of endovascular aortic repair. J Thorac Cardiovasc Surg. 2013;145(3 suppl):S72-S77. 237. Thomas M, Li Z, Cook DJ, Greason KL, Sundt TM. Contem-porary results of open aortic arch surgery. J Thorac Cardio-vasc Surg. 2012;144(4):838-844. 238. Urbanski PP, Lenos A, Bougioukakis P, et al. Mild-tomoderate hypothermia in aortic arch surgery using circula-tory arrest: a change of paradigm? Eur J Cardiothorac Surg. 2012;41(1):185-191. 239. Kondoh H, Taniguchi K, Funatsu T, et al. Total arch replace-ment with long elephant trunk anastomosed at the base of the innominate artery: a single-centre


Surgery_Schwartz

Surgery_Schwartz. Cardiothorac Surg. 2012;41(1):185-191. 239. Kondoh H, Taniguchi K, Funatsu T, et al. Total arch replace-ment with long elephant trunk anastomosed at the base of the innominate artery: a single-centre longitudinal experience. Eur J Cardiothorac Surg. 2012;42(5):840-848. 240. Flores J, Kunihara T, Shiiya N, et al. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury. J Thorac Cardiovasc Surg. 2006;131(2): 336-342. 241. Koullias GJ, Wheatley GH, III. State-of-the-art of hybrid pro-cedures for the aortic arch: a meta-analysis. Ann Thorac Surg. 2010;90(2):689-697. 242. Antoniou GA, Mireskandari M, Bicknell CD, et al. Hybrid repair of the aortic arch in patients with extensive aortic dis-ease. Eur J Vasc Endovasc Surg. 2010;40(6):715-721. 243. Geisbusch P, Kotelis D, Muller-Eschner M, Hyhlik-Durr A, Bockler D. Complications after aortic arch hybrid repair. J Vasc Surg. 2011;53(4):935-941. 244. Czerny M, Weigang E, Sodeck G, et al.


Surgery_Schwartz

Surgery_Schwartz. P, Kotelis D, Muller-Eschner M, Hyhlik-Durr A, Bockler D. Complications after aortic arch hybrid repair. J Vasc Surg. 2011;53(4):935-941. 244. Czerny M, Weigang E, Sodeck G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a trans-continental registry. Ann Thorac Surg. 2012;94(1):84-89. 245. Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the Inter-national Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140(4):784-789. 246. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg. 2007;83(1):55-61. 247. Pape LA, Awais M, Woznicki EM, et al. Presentation, diag-nosis, and outcomes of acute aortic dissection: 17-year trends From the International Registry of Acute Aortic Dissection. Brunicardi_Ch22_p0853-p0896.indd


Surgery_Schwartz

Surgery_Schwartz. Woznicki EM, et al. Presentation, diag-nosis, and outcomes of acute aortic dissection: 17-year trends From the International Registry of Acute Aortic Dissection. Brunicardi_Ch22_p0853-p0896.indd 89501/03/19 5:42 PM 896SPECIFIC CONSIDERATIONSPART IIJ Am Coll Cardiol. 2015;66(4):350-358. A comprehensive analysis of outcomes in patients with acute aortic dissection from the largest existing international registry. 248. Boening A, Karck M, Conzelmann LO, et al. German Registry for Acute Aortic Dissection Type A: structure, results, and future perspectives. Thorac Cardiovasc Surg. 2017;65(2):77-84. 249. Kruger T, Weigang E, Hoffmann I, et al. Cerebral protection during surgery for acute aortic dissection type A: results of the German Registry for Acute Aortic Dissection Type A (GERAADA). Circulation. 2011;124(4):434-443. 250. Dake MD, Miller DC, Mitchell RS, et al. The “first genera-tion” of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J


Surgery_Schwartz

Surgery_Schwartz. Circulation. 2011;124(4):434-443. 250. Dake MD, Miller DC, Mitchell RS, et al. The “first genera-tion” of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 1998;116(5):689-703. 251. Demers P, Miller DC, Mitchell RS, et al. Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts. J Thorac Cardiovasc Surg. 2004;127(3):664-673. 252. Bavaria JE, Appoo JJ, Makaroun MS, et al. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter compara-tive trial. J Thorac Cardiovasc Surg. 2007;133(2):369-377. 253. Fairman RM, Criado F, Farber M, et al. Pivotal results of the Medtronic Vascular Talent Thoracic Stent Graft System: the VALOR trial. J Vasc Surg. 2008;48(3):546-554. 254. Matsumura JS, Cambria RP, Dake MD, et al. International controlled clinical trial of thoracic endovascular aneurysm repair with


Surgery_Schwartz

Surgery_Schwartz. Graft System: the VALOR trial. J Vasc Surg. 2008;48(3):546-554. 254. Matsumura JS, Cambria RP, Dake MD, et al. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008;47(2):247-257. 255. Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008;47(5):912-918. 256. Foley PJ, Criado FJ, Farber MA, et al. Results with the Talent thoracic stent graft in the VALOR trial. J Vasc Surg. 2012;56(5):1214-1221 e1221. 257. Miller DC. Through the looking glass: The first 20 years of thoracic aortic stent-grafting. J Thorac Cardiovasc Surg. 2013;145(3 suppl):S142-S148. 258. Coselli JS, LeMaire SA, Conklin LD, Adams GJ. Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia. Ann Thorac Surg.


Surgery_Schwartz

Surgery_Schwartz. suppl):S142-S148. 258. Coselli JS, LeMaire SA, Conklin LD, Adams GJ. Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia. Ann Thorac Surg. 2004;77(4):1298-1303. 259. Chiesa R, Tshomba Y, Civilini E, et al. Open repair of descend-ing thoracic aneurysms. HSR Proc Intensive Care Cardiovasc Anesth. 2010;2(3):177-190. 260. Estrera AL, Miller CC, III, Chen EP, et al. Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage. Ann Thorac Surg. 2005;80(4):1290-1296. 261. LeMaire SA, Price MD, Green SY, Zarda S, Coselli JS. Results of open thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg. 2012;1(3):286-292. 262. Chiesa R, Melissano G, Civilini E, et al. Ten years experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned. Ann Vasc Surg. 2004;18(5):514-520. 263. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of


Surgery_Schwartz

Surgery_Schwartz. experience of thoracic and thoracoabdominal aortic aneurysm surgical repair: lessons learned. Ann Vasc Surg. 2004;18(5):514-520. 263. Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2007;83(2):S862-S864. 264. Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: a 20-year perspective. Ann Thorac Surg. 2007;83(2):S856-861. 265. Schepens MA, Kelder JC, Morshuis WJ, et al. Long-term follow-up after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 2007;83(2):S851-S855. 266. Rigberg DA, McGory ML, Zingmond DS, et al. Thirty-day mortality statistics underestimate the risk of repair of thora-coabdominal aortic aneurysms: a statewide experience. J Vasc Surg. 2006;43(2):217-222. 267. Cowan JA, Jr, Dimick JB, Henke PK, et al. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes. J Vasc Surg.


Surgery_Schwartz

Surgery_Schwartz. JA, Jr, Dimick JB, Henke PK, et al. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes. J Vasc Surg. 2003;37(6):1169-1174. 268. Wong DR, Parenti JL, Green SY, et al. Open repair of tho-racoabdominal aortic aneurysm in the modern surgical era: contemporary outcomes in 509 patients. J Am Coll Surg. 2011;212(4):569-579. 269. Coselli JS, LeMaire SA, Preventza O, et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151(5):1323-1337. This report describes the largest experience with open repair of thoracoabdominal aortic aneurysm and focuses on factors associated with adverse outcomes. 270. Trimarchi S, Tolenaar JL, Tsai TT, et al. Influence of clini-cal presentation on the outcome of acute B aortic dissec-tion: evidences from IRAD. J Cardiovasc Surg (Torino). 2012;53(2):161-168. 271. Tsai TT, Fattori R, Trimarchi S, et al. Long-term survival in patients presenting


Surgery_Schwartz

Surgery_Schwartz. the outcome of acute B aortic dissec-tion: evidences from IRAD. J Cardiovasc Surg (Torino). 2012;53(2):161-168. 271. Tsai TT, Fattori R, Trimarchi S, et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation. 2006;114(21):2226-2231. 272. Slonim SM, Miller DC, Mitchell RS, et al. Percutaneous balloon fenestration and stenting for life-threatening isch-emic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg. 1999;117(6):1118-1126. 273. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340(20):1546-1552. 274. Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascu-lar stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J. 2006;27(4):489-498. 275. White RA, Miller DC, Criado FJ, et al. Report on the results of thoracic endovascular aortic repair


Surgery_Schwartz

Surgery_Schwartz. stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J. 2006;27(4):489-498. 275. White RA, Miller DC, Criado FJ, et al. Report on the results of thoracic endovascular aortic repair for acute, complicated, type B aortic dissection at 30 days and 1 year from a multidisciplinary subcommittee of the Soci-ety for Vascular Surgery Outcomes Committee. J Vasc Surg. 2011;53(4):1082-1090. 276. Brunkwall J, Lammer J, Verhoeven E, Taylor P. ADSORB: a study on the efficacy of endovascular grafting in uncom-plicated acute dissection of the descending aorta. Eur J Vasc Endovasc Surg. 2012;44(1):31-36. 277. Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection pro-motes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg. 2014;48(3):285-291.Brunicardi_Ch22_p0853-p0896.indd 89601/03/19 5:42 PM


Surgery_Schwartz

Surgery_Schwartz. Arterial DiseasePeter H. Lin, Carlos F. Bechara, Changyi Chen, and Frank J. Veith 23chapterGeneral Approach to the Vascular Patient 898The Vascular History / 898The Vascular Physical Examination / 899Noninvasive Diagnostic Evaluation of the Vascular Patient / 899Radiologic Evaluation of the Vascular Patient / 900Preoperative Cardiac Evaluation / 903Basic Principles of Endovascular Therapy 903Needles and Access / 904Guidewires / 904Hemostatic Sheaths / 905Catheters / 905Angioplasty Balloons / 905Stents / 905Stent Grafts / 906Carotid Artery Disease 907Epidemiology and Etiology of Carotid Occlusive Disease / 907Clinical Manifestations of Cerebral Ischemia / 907Diagnostic Evaluation / 909Treatment of Carotid Occlusive Disease / 910Carotid Endarterectomy Versus Angioplasty and Stenting / 911Surgical Techniques of Carotid Endarterectomy / 912Techniques of Carotid Angioplasty and Stenting / 914Nonatherosclerotic Disease of the Carotid Artery / 916Abdominal Aortic Aneurysm 919Causes


Surgery_Schwartz

Surgery_Schwartz. / 911Surgical Techniques of Carotid Endarterectomy / 912Techniques of Carotid Angioplasty and Stenting / 914Nonatherosclerotic Disease of the Carotid Artery / 916Abdominal Aortic Aneurysm 919Causes and Risk Factors / 919Natural History of Aortic Aneurysm / 920Clinical Manifestations / 920Relevant Anatomy / 920Diagnostic Evaluation / 921Surgical Repair of Abdominal Aortic Aneurysm / 921Endovascular Repair of Abdominal Aortic Aneurysm / 922Results From Clinical Studies Comparing Endovascular Versus Open Repair / 925Classification and Management of Endoleak / 927Mesenteric Artery Disease 928Anatomy and Pathophysiology / 928Types of Mesenteric Artery Occlusive Disease / 929Clinical Manifestations / 930Diagnostic Evaluation / 930Surgical Repair / 932Endovascular Treatment / 933Clinical Results of Interventions for Mesenteric Ischemia / 934Renal Artery Disease 935Etiology / 935Clinical Manifestations / 936Diagnostic Evaluation / 936Treatment Indications / 937Surgical Reconstruction /


Surgery_Schwartz

Surgery_Schwartz. of Interventions for Mesenteric Ischemia / 934Renal Artery Disease 935Etiology / 935Clinical Manifestations / 936Diagnostic Evaluation / 936Treatment Indications / 937Surgical Reconstruction / 938Clinical Results of Surgical Repair / 938Endovascular Treatment / 938Clinical Results of Endovascular Interventions / 939Aortoiliac Occlusive Disease 940Diagnostic Evaluation / 941Differential Diagnosis / 941Collateral Arterial Network / 941Disease Classification / 941General Treatment Considerations / 943Surgical Reconstruction of Aortoiliac Occlusive Disease / 944Complications of Surgical Aortoiliac Reconstruction / 946Endovascular Treatment for Aortic Disease / 947Endovascular Treatment for Iliac Artery Disease / 948Complications of Endovascular Aortoiliac Interventions / 949Clinical Results Comparing Surgical and Endovascular Treatment of Aortoiliac Disease / 949Lower Extremity Arterial Occlusive Disease 950Epidemiology / 950Diagnostic Evaluation / 950Differential Diagnosis /


Surgery_Schwartz

Surgery_Schwartz. Results Comparing Surgical and Endovascular Treatment of Aortoiliac Disease / 949Lower Extremity Arterial Occlusive Disease 950Epidemiology / 950Diagnostic Evaluation / 950Differential Diagnosis / 951Lower Extremity Occlusive Disease Classification / 951Etiology of Acute Limb Ischemia / 952Clinical Manifestations of Acute Limb Ischemia / 954Treatment Considerations for Acute Limb Ischemia / 955Endovascular Treatment / 955Surgical Treatment / 956Complications Related to Treatment for Acute Limb Ischemia / 956Clinical Manifestations of Chronic Limb Ischemia / 958Treatment Considerations for Chronic Limb Ischemia / 959Endovascular Treatment / 960Complications of Endovascular Interventions / 965Surgical Treatment for Chronic Limb Ischemia due to Femoropopliteal Disease / 966Complications of Surgical Reconstruction / 966Choice of Conduit for Infrainguinal Bypass Grafting / 967Clinical Results of Surgical and Endovascular Interventions for Femoropopliteal Occlusive Disease /


Surgery_Schwartz

Surgery_Schwartz. of Surgical Reconstruction / 966Choice of Conduit for Infrainguinal Bypass Grafting / 967Clinical Results of Surgical and Endovascular Interventions for Femoropopliteal Occlusive Disease / 968Nonatherosclerotic Disorders of Blood Vessels 969Giant Cell Arteritis (Temporal Arteritis) / 969Takayasu’s Arteritis / 969Ehlers-Danlos Syndrome / 970Marfan’s Syndrome / 970Pseudoxanthoma Elasticum / 970Kawasaki’s Disease / 971Inflammatory Arteritis and Vasculitis / 971Behçet’s Disease / 971Polyarteritis Nodosa / 971Radiation-Induced Arteritis / 972Raynaud’s Syndrome / 972Fibromuscular Dysplasia / 972Nonatherosclerotic Disease Affecting the Popliteal Artery Disease / 973Buerger’s Disease (Thromboangiitis Obliterans) / 974Brunicardi_Ch23_p0897-p0980.indd 89727/02/19 4:13 PM 898Table 23-1Pertinent elements in vascular history• History of stroke or transient ischemic attack• History of coronary artery disease, including previous myocardial infarction and angina• History of peripheral


Surgery_Schwartz

Surgery_Schwartz. elements in vascular history• History of stroke or transient ischemic attack• History of coronary artery disease, including previous myocardial infarction and angina• History of peripheral arterial disease• History of diabetes• History of hypertension• History of tobacco use• History of hyperlipidemiaGENERAL APPROACH TO THE VASCULAR PATIENTSince the vascular system involves every organ system in our body, the symptoms of vascular disease are as varied as those encountered in any medical specialty. Lack of adequate blood supply to target organs typically presents with pain, for exam-ple, calf pain with lower extremity claudication, postprandial abdominal pain from mesenteric ischemia, and arm pain with axillo-subclavian arterial occlusion. In contrast, stroke and tran-sient ischemic attack (TIA) are the presenting symptoms from middle cerebral embolization as a consequence of a stenosed internal carotid artery. The pain syndrome of arterial disease is usually divided clinically into


Surgery_Schwartz

Surgery_Schwartz. (TIA) are the presenting symptoms from middle cerebral embolization as a consequence of a stenosed internal carotid artery. The pain syndrome of arterial disease is usually divided clinically into acute and chronic types, with all shades of severity between the two extremes. Sudden onset of pain can indicate complete occlusion of a critical vessel, leading to more severe pain and critical ischemia in the target organ, resulting in lower limb gangrene or intestinal infarction. Chronic pain results from a slower, more progressive atheroscle-rotic occlusion, which can be totally or partially compensated by developing collateral vessels. Acute on chronic is another pain pattern in which a patient most likely has an underlying arterial stenosis that suddenly occludes, for example, the patient with a history of calf claudication who now presents with sudden, severe acute limb-threatening ischemia. The clinician should always try to understand and relate the clinical manifestations to the


Surgery_Schwartz

Surgery_Schwartz. with a history of calf claudication who now presents with sudden, severe acute limb-threatening ischemia. The clinician should always try to understand and relate the clinical manifestations to the underlying pathologic process.The Vascular HistoryAppropriate history should be focused based on the present-ing symptoms related to the vascular system (Table 23-1). Of particular importance in the previous medical history is noting prior vascular interventions (endovascular or open surgical), and all vascular patients should have inquiry made about their prior cardiac history and current cardiac symptoms. Approximately 30% of vascular patients will be diabetic. A history of prior and current smoking status should be noted.The patient with carotid disease in most cases is com-pletely asymptomatic, having been referred based on the find-ing of a cervical bruit or duplex finding of stenosis. Symptoms of carotid territory TIAs include transient monocular blindness (amaurosis), contralateral


Surgery_Schwartz

Surgery_Schwartz. having been referred based on the find-ing of a cervical bruit or duplex finding of stenosis. Symptoms of carotid territory TIAs include transient monocular blindness (amaurosis), contralateral weakness or numbness, and dys-phasia. Symptoms persisting longer than 24 hours constitute a stroke. In contrast, the patient with chronic mesenteric isch-emia is likely to present with postprandial abdominal pain and weight loss. The patient fears eating because of the pain, avoids food, and loses weight. It is very unlikely that a patient with abdominal pain who has not lost weight has chronic mesenteric ischemia.The patient with lower extremity pain on ambulation has intermittent claudication that occurs in certain muscle groups; for example, calf pain upon exercise usually reflects superficial femoral artery disease, while pain in the buttocks reflects iliac disease. In most cases, the pain manifests in one muscle group below the level of the affected artery, occurs only with exercise, and


Surgery_Schwartz

Surgery_Schwartz. femoral artery disease, while pain in the buttocks reflects iliac disease. In most cases, the pain manifests in one muscle group below the level of the affected artery, occurs only with exercise, and is relieved with rest only to recur at the same location, hence the term “window gazer’s disease.” Rest pain (a manifestation of severe underlying occlusive disease) is constant and occurs in the foot (not the muscle groups), typically at the metatarso-phalangeal junction, and is relieved by dependency. Often the Key Points1 Carotid intervention as a preventive strategy should be per-formed in patients with 60% or greater symptomatic internal carotid artery stenosis and those with 80% or greater asymp-tomatic internal carotid artery stenosis. Carotid intervention for asymptomatic stenosis between 60% and 79% remains controversial. The modality of carotid intervention—carotid endarterectomy versus carotid stenting—remains contro-versial; currently, carotid endarterectomy appears to be


Surgery_Schwartz

Surgery_Schwartz. between 60% and 79% remains controversial. The modality of carotid intervention—carotid endarterectomy versus carotid stenting—remains contro-versial; currently, carotid endarterectomy appears to be associated with lower stroke rate with long term durability, whereas carotid stenting is more suitable under certain chal-lenging anatomic or physiologic conditions.2 Abdominal aortic aneurysms should be repaired when the risk of rupture, determined mainly by aneurysm size, exceeds the risk of death due to perioperative complications or concurrent illness. Endovascular repair is associated with less perioperative morbidity and mortality compared with open reconstruction and is preferred in patients with suitable anatomic morphology for stent-graft placement.3 Treatment objectives for symptomatic mesenteric ischemia are to improve quality of life and prevent bowel infarc-tion. Endovascular intervention with stenting has similar treatment efficacy comparative with less perioperative


Surgery_Schwartz

Surgery_Schwartz. mesenteric ischemia are to improve quality of life and prevent bowel infarc-tion. Endovascular intervention with stenting has similar treatment efficacy comparative with less perioperative mor-bidity compared to open mesenteric bypass. Surgical recon-struction has a proven durability and patency rate compared with endovascular intervention.4 Aortoiliac occlusive disease can be treated with either endovascular means or open reconstruction, depending on patient risk stratification, occlusion characteristics, and symptomatology.5 Claudication is a marker of extensive atherosclerosis and is mainly managed with risk factor modification and pharma-cotherapy. Only 5% of patients with claudication will need intervention because of disabling extremity pain. The 5-year mortality of a patient with claudication approaches 30%. Patients with rest pain or tissue loss need expeditious evalu-ation and vascular reconstruction to ameliorate the severe extremity pain and prevent limb loss. Endovascular


Surgery_Schwartz

Surgery_Schwartz. approaches 30%. Patients with rest pain or tissue loss need expeditious evalu-ation and vascular reconstruction to ameliorate the severe extremity pain and prevent limb loss. Endovascular interven-tion is preferred as the first line of therapy for lower extrem-ity occlusive disease, whereas bypass reconstruction should be considered in failed endovascular therapy or long seg-ment femoropopliteal occlusive disease.Brunicardi_Ch23_p0897-p0980.indd 89827/02/19 4:13 PM 899ARTERIAL DISEASECHAPTER 23Table 23-2Grading scales for peripheral pulsesTRADITIONAL SCALEBASIC SCALE4+Normal2+Normal3+Slightly reduced1+Diminished2+Markedly reduced0Absent1+Barely palpable patient is prompted to sleep with their foot hanging off one side of the bed to increase the hydrostatic pressure.The Vascular Physical ExaminationSpecific vascular examination should include abdominal aortic palpation, carotid artery examination, and pulse examination of the lower extremity (femoral, popliteal, posterior tibial,


Surgery_Schwartz

Surgery_Schwartz. ExaminationSpecific vascular examination should include abdominal aortic palpation, carotid artery examination, and pulse examination of the lower extremity (femoral, popliteal, posterior tibial, and dorsalis pedis arteries). The abdomen should be palpated for an abdominal aortic aneurysm, detected as an expansile pulse above the level of the umbilicus. It should also be examined for the presence of bruits. Because the aorta typically divides at the level of the umbilicus, an aortic aneurysm is most frequently palpable in the epigastrium. In thin individuals, a normal aortic pulsation is palpable, while in obese patients, even large aor-tic aneurysms may not be detectable. Suspicion of a clinically enlarged aorta should lead to the performance of an ultrasound scan for a more accurate definition of aortic diameter.The carotids should be auscultated for the presence of bruits, although there is a higher correlation with coronary artery disease than underlying carotid stenosis. A bruit


Surgery_Schwartz

Surgery_Schwartz. of aortic diameter.The carotids should be auscultated for the presence of bruits, although there is a higher correlation with coronary artery disease than underlying carotid stenosis. A bruit at the angle of the mandible is a significant finding, leading to follow-up duplex scanning. The differential diagnosis is a transmitted murmur from a sclerotic or stenotic aortic valve. The carotid is palpable deep to the sternocleidomastoid muscle in the neck. Palpation, however, should be gentle and rarely yields clinically useful information.Upper extremity examination is necessary when an arte-riovenous graft is to be inserted in patients who have symptoms of arm pain with exercise. Thoracic outlet syndrome (TOS) can result in occlusion or aneurysm formation of the subclavian artery. Distal embolization is a manifestation of TOS; conse-quently, the fingers should be examined for signs of ischemia and ulceration. The axillary artery enters the limb below the middle of the clavicle, where it


Surgery_Schwartz

Surgery_Schwartz. is a manifestation of TOS; conse-quently, the fingers should be examined for signs of ischemia and ulceration. The axillary artery enters the limb below the middle of the clavicle, where it can be palpated in thin patients. It is usually easily palpable in the axilla and medial upper arm. The brachial artery is most easily located at the antecubital fossa immediately medial to the biceps tendon. The radial artery is palpable at the wrist anterior to the radius.For lower extremity vascular examination, the femoral pulse is usually palpable midway between the anterior supe-rior iliac spine and the pubic tubercle. The popliteal artery is palpated in the popliteal fossa with the knee flexed to 45° and the foot supported on the examination table to relax the calf muscles. Palpation of the popliteal artery is a bimanual tech-nique. Both thumbs are placed on the tibial tuberosity anteriorly, and the fingers are placed into the popliteal fossa between the two heads of the gastrocnemius


Surgery_Schwartz

Surgery_Schwartz. popliteal artery is a bimanual tech-nique. Both thumbs are placed on the tibial tuberosity anteriorly, and the fingers are placed into the popliteal fossa between the two heads of the gastrocnemius muscle. The popliteal artery is palpated by compressing it against the posterior aspect of the tibia just below the knee. The posterior tibial pulse is detected by palpation 2 cm posterior to the medial malleolus. The dorsa-lis pedis is detected 1 cm lateral to the hallucis longus extensor tendon, which dorsiflexes the great toe and is clearly visible on the dorsum of the foot. Pulses can be graded using either the traditional four-point scale or the basic two-point scale system (Table 23-2). The foot should also be carefully examined for pallor on elevation and rubor on dependency, as these findings are indicative of chronic ischemia. Note should also be made of nail changes and loss of hair. Ulceration and other findings specific to disease states are described in relevant sections later


Surgery_Schwartz

Surgery_Schwartz. are indicative of chronic ischemia. Note should also be made of nail changes and loss of hair. Ulceration and other findings specific to disease states are described in relevant sections later in this chapter.After reconstructive vascular surgery, the graft may be available for examination, depending on its type and course. The in situ lower extremity graft runs in the subcutaneous fat and can be palpated along most of its length. A change in pulse quality, aneurysmal enlargement, or a new bruit should be care-fully noted. Axillofemoral grafts, femoral-to-femoral grafts, and arteriovenous access grafts can usually be easily palpated as well.Noninvasive Diagnostic Evaluation of the Vascular PatientAnkle-Brachial Index. There is increasing interest in the use of the ankle-brachial index (ABI) to evaluate patients at risk for cardiovascular events. An ABI less than 0.9 correlates with increased risk of myocardial infarction and indicates significant, although perhaps asymptomatic,


Surgery_Schwartz

Surgery_Schwartz. (ABI) to evaluate patients at risk for cardiovascular events. An ABI less than 0.9 correlates with increased risk of myocardial infarction and indicates significant, although perhaps asymptomatic, underlying peripheral vascular disease. The ABI is determined in the following ways. Blood pressure is measured in both upper extremities using the high-est systolic blood pressure as the denominator for the ABI. The ankle pressure is determined by placing a blood pressure cuff above the ankle and measuring the return to flow of the posterior tibial and dorsalis pedis arteries using a pencil Doppler probe over each artery. The ratio of the systolic pressure in each ves-sel divided by the highest arm systolic pressure can be used to express the ABI in both the posterior tibial and dorsalis pedis arteries (Fig. 23-1). Normal is more than 1. Patients with clau-dication typically have an ABI in the 0.5 to 0.7 range, and those with rest pain are in the 0.3 to 0.5 range. Those with gangrene have


Surgery_Schwartz

Surgery_Schwartz. arteries (Fig. 23-1). Normal is more than 1. Patients with clau-dication typically have an ABI in the 0.5 to 0.7 range, and those with rest pain are in the 0.3 to 0.5 range. Those with gangrene have an ABI of less than 0.3. These ranges can vary depending on the degree of compressibility of the vessel. The test is less reliable in patients with heavily calcified vessels. Due to non-compressibility, some patients, such as diabetics and those with end-stage renal disease, may have ABI ≥1.40 and require addi-tional noninvasive diagnostic testing to evaluate for peripheral artery disease. Alternative tests include toe-brachial pressures, pulse volume recordings, transcutaneous oxygen measurements, or vascular imaging (duplex ultrasound).Segmental Limb Pressures. By placing serial blood pressure cuffs down the lower extremity and then measuring the pressure with a Doppler probe as flow returns to the artery below the cuff, it is possible to determine segmental pressures down the leg. This


Surgery_Schwartz

Surgery_Schwartz. cuffs down the lower extremity and then measuring the pressure with a Doppler probe as flow returns to the artery below the cuff, it is possible to determine segmental pressures down the leg. This data can then be used to infer the level of the occlu-sion. The systolic pressure at each level is expressed as a ratio, with the highest systolic pressure in the upper extremities as the denominator. Normal segmental pressures commonly show high thigh pressures 20 mmHg or greater in comparison to the brachial artery pressures. The low thigh pressure should be equivalent to brachial pressures. Subsequent pressures should fall by no more than 10 mmHg at each level. A pressure gradient of 20 mmHg between two subsequent levels is usually indica-tive of occlusive disease at that level. The most frequently used index is the ratio of the ankle pressure to the brachial pressure, Brunicardi_Ch23_p0897-p0980.indd 89927/02/19 4:13 PM 900SPECIFIC CONSIDERATIONSPART IIFigure 23-1. Calculating the


Surgery_Schwartz

Surgery_Schwartz. used index is the ratio of the ankle pressure to the brachial pressure, Brunicardi_Ch23_p0897-p0980.indd 89927/02/19 4:13 PM 900SPECIFIC CONSIDERATIONSPART IIFigure 23-1. Calculating the ankle-brachial index (ABI).Right ABI = ratio ofHigher of the right ankle systolic pressures (posterior tibial or dorsalis pedis)Higher arm systolic pressure (left or right arm)Left ABI = ratio ofHigher of the left ankle systolic pressures (posterior tibial or dorsalis pedis)Higher arm systolic pressure (left or right arm)the ABI. Normally, the ABI is greater than 1.0, and a value of less than 0.9 indicates some degree of arterial obstruction and has been shown to be correlated with an increased risk of coronary heart disease. Limitations of relying on segmental limb pressures include: (a) missing isolated moderate stenoses (usually iliac) that produce little or no pressure gradient at rest; (b) falsely elevated pressures in patients with diabetes and end-stage renal disease; and (c) the inability


Surgery_Schwartz

Surgery_Schwartz. moderate stenoses (usually iliac) that produce little or no pressure gradient at rest; (b) falsely elevated pressures in patients with diabetes and end-stage renal disease; and (c) the inability to differentiate between stenosis and occlusion.1 Patients with diabetes and end-stage renal disease have calcified vessels that are difficult to com-press, thus rendering this method inaccurate, due to recording of falsely elevated pressure readings. Noncompressible arter-ies yield ankle systolic pressures ≥250 mmHg and ABIs >1.40. In this situation, absolute toe and ankle pressures can be mea-sured to gauge critical limb ischemia. Ankle pressures less than 50 mmHg or toe pressures less than 30 mmHg are indica-tive of critical limb ischemia. The toe pressure is normally 30 mmHg less than the ankle pressure, and a toe-brachial index (TBI) <0.70 is abnormal. False-positive results with the TBI are unusual. The main limitation of this technique is that it may be impossible to measure pressures


Surgery_Schwartz

Surgery_Schwartz. pressure, and a toe-brachial index (TBI) <0.70 is abnormal. False-positive results with the TBI are unusual. The main limitation of this technique is that it may be impossible to measure pressures in the first and second toes due to preexisting ulceration.Pulse Volume Recording. In patients with noncompressible vessels, segmental plethysmography can be used to determine underlying arterial occlusive disease. Cuffs placed at different levels on the leg detect changes in blood volume and produce a pulse volume recording (PVR) when connected to a plethysmo-graph (Fig. 23-2). To obtain accurate PVR waveforms, the cuff is inflated to 60 to 65 mmHg, so as to detect volume changes without causing arterial occlusion. Pulse volume tracings are suggestive of proximal disease if the upstroke of the pulse is not brisk, the peak of the wave tracing is rounded, and there is disappearance of the dicrotic notch.Although isolated segmental limb pressures and PVR mea-surements are 85% accurate when


Surgery_Schwartz

Surgery_Schwartz. pulse is not brisk, the peak of the wave tracing is rounded, and there is disappearance of the dicrotic notch.Although isolated segmental limb pressures and PVR mea-surements are 85% accurate when compared with angiography in detecting and localizing significant atherosclerotic lesions, when used in combination, accuracy approaches 95%.2 For this reason, it is suggested that these two diagnostic modalities be used in combination when evaluating peripheral artery disease.Radiologic Evaluation of the Vascular PatientUltrasound. Ultrasound examinations are relatively time consuming, require experienced technicians, and may not visu-alize all arterial segments. Doppler waveform analysis can sug-gest atherosclerotic occlusive disease if the waveforms in the insonated arteries are biphasic, monophasic, or asymmetrical. B-mode ultrasonography provides black and white, real-time images. B-mode ultrasonography does not evaluate blood flow; thus, it cannot differentiate between fresh thrombus


Surgery_Schwartz

Surgery_Schwartz. or asymmetrical. B-mode ultrasonography provides black and white, real-time images. B-mode ultrasonography does not evaluate blood flow; thus, it cannot differentiate between fresh thrombus and flow-ing blood, which have the same echogenicity. Calcification in atherosclerotic plaques will cause acoustic shadowing. B-mode ultrasound probes cannot be sterilized. Use of the B-mode probe intraoperatively requires a sterile covering and gel to maintain an acoustic interface. Experience is needed to obtain and interpret images accurately. Duplex ultrasonography entails performance of B-mode imaging, spectral Doppler scanning, and color-flow duplex scanning. The caveat to performance of duplex ultraso-nography is meticulous technique by a certified vascular ultra-sound technician, so that the appropriate 60° Doppler angle is maintained during insonation with the ultrasound probe. Altera-tion of this angle can markedly alter waveform appearance and subsequent interpretation of velocity


Surgery_Schwartz

Surgery_Schwartz. the appropriate 60° Doppler angle is maintained during insonation with the ultrasound probe. Altera-tion of this angle can markedly alter waveform appearance and subsequent interpretation of velocity measurements. Direct imaging of intra-abdominal vessels with duplex ultrasound is less reliable because of the difficulty in visualizing the vessels through overlying bowel. These disadvantages currently limit the applicability of duplex scanning in the evaluation of aortoil-iac and infrapopliteal disease. A clinical study has shown that duplex ultrasonography had lower sensitivity in the calculation of infrapopliteal vessel stenosis in comparison to conventional digital subtraction or computed tomography angiography.3 Few surgeons rely solely on duplex ultrasonography for preopera-tive planning in lower extremity revascularizations; but with experience, lower extremity arteries can be insonated to deter-mine anatomy, and the functional significance of lesions can be determined by


Surgery_Schwartz

Surgery_Schwartz. planning in lower extremity revascularizations; but with experience, lower extremity arteries can be insonated to deter-mine anatomy, and the functional significance of lesions can be determined by calculation of degree of stenosis from velocity ratios. Duplex scanning is unable to evaluate recently implanted polytetrafluoroethylene (PTFE) and polyester (Dacron) grafts because they contain air, which prevents ultrasound penetration.Computed Tomography Angiography. Computed tomogra-phy angiography (CTA) is a noninvasive, contrast-dependent method for imaging the arterial system. It depends on intrave-nous infusion of iodine-based contrast agents. The patient is advanced through a rotating gantry, which images serial trans-verse slices. The contrast-filled vessels can be extracted from the slices and rendered in three-dimensional format (Fig. 23-3). Brunicardi_Ch23_p0897-p0980.indd 90027/02/19 4:13 PM 901ARTERIAL DISEASECHAPTER 23Figure 23-2. Typical report of peripheral vascular


Surgery_Schwartz

Surgery_Schwartz. slices and rendered in three-dimensional format (Fig. 23-3). Brunicardi_Ch23_p0897-p0980.indd 90027/02/19 4:13 PM 901ARTERIAL DISEASECHAPTER 23Figure 23-2. Typical report of peripheral vascular study with arterial segmental pressure measurement plus Doppler evaluation of the lower extremity.Femoral0.750.500.250.000.25Sup.femoral1.501.000.500.000.50Popliteal1.501.000.500.000.50Posteriortibial1.501.000.500.000.50Dorsalispedis0.750.500.250.000.250.75Femoral0.500.250.000.25Popliteal0.750.500.250.000.25Posteriortibial0.750.500.250.000.25Dorsalispedis0.750.500.250.000.25Sup.femoral0.750.500.250.250.00149Brachial0.66U. thighL. thighCalfAnkle-PTAnkle-DPToe0.770.741.011.051.011.050.700.730.660.620.59Indexes144RightLeftDoppler waveforms1 sec/div15715015710910599PT 98DT 92PT 151DT 11111488ABFigure 23-3. A multidetector computed tomography angiography with three-dimensional reconstruction of the iliofemoral arterial circulation in two patients with lower leg claudication. A. A 50-year-old man


Surgery_Schwartz

Surgery_Schwartz. 23-3. A multidetector computed tomography angiography with three-dimensional reconstruction of the iliofemoral arterial circulation in two patients with lower leg claudication. A. A 50-year-old man with an occluded right superficial femoral artery (single long arrow) with reconstituted superficial femoral artery at the level of mid-thigh. Arterial calcifications (single short arrows) are present in the bilateral distal superficial femoral arteries. B. A 53-year-old man with occluded right common iliac artery (double arrows).The extracted images can also be rotated and viewed from sev-eral different directions during postacquisition image process-ing. This technology has been advanced as a consequence of aortic endografting. CTA provides images for postprocessing that can be used to display the aneurysm in a format that demon-strates thrombus, calcium, lumen, and the outer wall, and allows “fitting” of a proposed endograft into the aneurysm (Fig. 23-4). CTA is increasingly being used


Surgery_Schwartz

Surgery_Schwartz. the aneurysm in a format that demon-strates thrombus, calcium, lumen, and the outer wall, and allows “fitting” of a proposed endograft into the aneurysm (Fig. 23-4). CTA is increasingly being used to image the carotid bifurca-tion, and as computing power increases, the speed of image acquisition and resolution will continue to increase. The major limitations of multidetector CTA are use of contrast and pres-ence of artifacts caused by calcification and stents. CTA can Brunicardi_Ch23_p0897-p0980.indd 90127/02/19 4:13 PM 902SPECIFIC CONSIDERATIONSPART IIFigure 23-4. Three-dimensional computed tomog-raphy angiogram of an abdominal aortic aneurysm that displays various aneurysm components including thrombus, aortic calcification, blood circulation, and aneurysm wall.Figure 23-5. Magnetic resonance angiogram of aortic arch and carotid arteries. This study can provide a three-dimensional analysis of vascular structure such as aortic arch branches and carotid and vertebral


Surgery_Schwartz

Surgery_Schwartz. resonance angiogram of aortic arch and carotid arteries. This study can provide a three-dimensional analysis of vascular structure such as aortic arch branches and carotid and vertebral arteries.overestimate the degree of in-stent stenosis, while heavy calci-fication can limit the diagnostic accuracy of the method by caus-ing a “blooming artifact.”4 The artifacts can be overcome with alteration in image acquisition technique. There are no random-ized trials to document the superiority of multidetector CTA over traditional angiography, but there is emerging evidence to support the claim that multidetector CTA has sensitivity, speci-ficity, and accuracy that rival invasive angiography.4Magnetic Resonance Angiography. Magnetic resonance angiography (MRA) has the advantage of not requiring iodin-ated contrast agents to provide vessel opacification (Fig. 23-5). Gadolinium is used as a contrast agent for MRA studies, and because it is generally not nephrotoxic, it can be used in patients


Surgery_Schwartz

Surgery_Schwartz. iodin-ated contrast agents to provide vessel opacification (Fig. 23-5). Gadolinium is used as a contrast agent for MRA studies, and because it is generally not nephrotoxic, it can be used in patients with elevated creatinine. MRA is contraindicated in patients with pacemakers, defibrillators, spinal cord stimulators, intrace-rebral shunts, cochlear implants, and cranial clips. Patients with claustrophobia may require sedation to be able to complete the test. The presence of metallic stents causes artifacts and signal drop-out; however, these can be dealt with using alternations in image acquisition and processing. Nitinol stents produce mini-mal artifact. Compared to other modalities, MRA is relatively slow and expensive. However, due to its noninvasive nature and decreased nephrotoxicity, MRA is being used more frequently for imaging vasculature in various anatomic distributions.Diagnostic Angiography. Diagnostic angiography is consid-ered the gold standard in vascular imaging. In


Surgery_Schwartz

Surgery_Schwartz. MRA is being used more frequently for imaging vasculature in various anatomic distributions.Diagnostic Angiography. Diagnostic angiography is consid-ered the gold standard in vascular imaging. In many centers, its use is rapidly decreasing due to the development of noninvasive imaging modalities such as duplex arterial mapping, CTA, and MRA. Nevertheless, contrast angiography still remains in wide-spread use. The essential aspects of angiography are vascular access and catheter placement in the vascular bed that requires examination. The imaging system and the contrast agent are used to opacify the target vessel. Although in the past this func-tion has largely been delegated to the interventional radiology service, an increasing number of surgeons are performing this procedure and following the diagnostic imaging with immediate surgical or endovascular intervention. There are several consid-erations when relying on angiography for imaging.Approximately 70% of atherosclerotic plaques


Surgery_Schwartz

Surgery_Schwartz. the diagnostic imaging with immediate surgical or endovascular intervention. There are several consid-erations when relying on angiography for imaging.Approximately 70% of atherosclerotic plaques occur in an eccentric location within the blood vessel; therefore, images can be misleading when trying to evaluate stenoses because angiog-raphy is limited to a uniplanar “lumenogram.” With increased use of intravascular stent deployment, it has also been noted that assessment of stent apposition and stent position in rela-tion to surrounding branches may be inaccurate. Furthermore, angiography exposes the patient to the risks of both ionizing radiation and intravascular contrast. Nevertheless, contrast angi-ography remains the most common invasive method of vascular investigation for both diagnostic and therapeutic intervention. The angiogram usually provides the final information needed to decide whether or not to proceed with operation or endovascular interventions.Digital subtraction


Surgery_Schwartz

Surgery_Schwartz. and therapeutic intervention. The angiogram usually provides the final information needed to decide whether or not to proceed with operation or endovascular interventions.Digital subtraction angiography (DSA) offers some advan-tages over conventional cut-film angiography such as excellent visualization despite use of lower volumes of contrast media. In particular, when multilevel occlusive lesions limit the amount of contrast reaching distal vessels, supplemental use of digital sub-traction angiographic techniques may enhance visualization and definition of anatomy. Intra-arterial DSA uses a portable, axially Brunicardi_Ch23_p0897-p0980.indd 90227/02/19 4:13 PM 903ARTERIAL DISEASECHAPTER 23Figure 23-6. Digital subtraction angiography (DSA) provides excellent visualization of intravascular circulation with intra-arterial contrast administration. As depicted in this DSA study, multilevel lesions are demonstrated, which include a focal left iliac artery stenosis (large arrow), right


Surgery_Schwartz

Surgery_Schwartz. circulation with intra-arterial contrast administration. As depicted in this DSA study, multilevel lesions are demonstrated, which include a focal left iliac artery stenosis (large arrow), right superficial femoral occlusion (curved arrows), left superficial femoral stenosis (small arrow), and mul-tiple tibial artery stenoses (arrowheads).rotatable imaging device that can obtain views from different angles. DSA also allows for real-time video replay (Fig. 23-6). An entire extremity can be filmed with DSA using repeated injections of small amounts of contrast agent to obtain sequen-tial angiographic images, the so-called pulse-chase technique.Preoperative Cardiac EvaluationThe most important and most controversial aspect of preopera-tive evaluation in patients with atherosclerotic disease requiring surgical intervention is the detection and subsequent manage-ment of associated coronary artery disease. Several studies have documented the existence of significant coronary artery disease


Surgery_Schwartz

Surgery_Schwartz. requiring surgical intervention is the detection and subsequent manage-ment of associated coronary artery disease. Several studies have documented the existence of significant coronary artery disease in 40% to 50% or more of patients requiring peripheral vascular reconstructive procedures, 10% to 20% of whom may be relatively asymptomatic largely because of their inability to exercise.5 Myocardial infarction is responsible for the major-ity of both early and late postoperative deaths. Most available screening methods lack sensitivity and specificity to predict postoperative cardiac complications. There have been conflict-ing reports regarding the utility of preoperative dipyridamole-thallium nuclear imaging or dobutamine-echocardiography to stratify vascular patients in terms of perioperative cardiac mor-bidity and mortality. In nearly half of patients, thallium imaging proves to be unnecessary because cardiac risk can be predicted by clinical information alone.6 Even with coronary


Surgery_Schwartz

Surgery_Schwartz. cardiac mor-bidity and mortality. In nearly half of patients, thallium imaging proves to be unnecessary because cardiac risk can be predicted by clinical information alone.6 Even with coronary angiography, it is difficult to relate anatomic findings to functional signifi-cance and, hence, surgical risk. There are no data confirming that percutaneous coronary interventions or surgical revascu-larization prior to vascular surgical procedures impact mortality or incidence of myocardial infarctions. In fact, coronary angi-ography is associated with its own inherent risks, and patients undergoing coronary artery bypass grafting or coronary percuta-neous transluminal angioplasty (PTA) before needed aortoiliac reconstructions are subjected to the risks and complications of both procedures.The Coronary Artery Revascularization Prophylaxis (CARP) trial showed that coronary revascularization in patients with peripheral vascular disease and significant coronary artery disease, who are considered


Surgery_Schwartz

Surgery_Schwartz. Artery Revascularization Prophylaxis (CARP) trial showed that coronary revascularization in patients with peripheral vascular disease and significant coronary artery disease, who are considered high risk for perioperative com-plications, did not reduce overall mortality or perioperative myocardial infarction.7 Additionally, patients who underwent prophylactic coronary revascularization had significant delays prior to undergoing their vascular procedure and increased limb morbidity compared to patients who did not. Studies do support improvement in cardiovascular and overall prognosis with med-ical optimization of patients.8 Therefore, use of perioperative β-blockade, as well as use of antiplatelet medication, statins, and angiotensin-converting enzyme inhibitors, is encouraged in vascular patients.BASIC PRINCIPLES OF ENDOVASCULAR THERAPYCardiovascular disease remains a major cause of mortality in the developed world since the beginning of the 21st century. Although surgical


Surgery_Schwartz

Surgery_Schwartz. vascular patients.BASIC PRINCIPLES OF ENDOVASCULAR THERAPYCardiovascular disease remains a major cause of mortality in the developed world since the beginning of the 21st century. Although surgical revascularization has played a predominant role in the management of patients with vascular disease, the modern treatment paradigms have evolved significantly with increased emphasis of catheter-based percutaneous interven-tions over the past two decades. The increasing role of this mini-mally invasive vascular intervention is fueled by various factors, including rapid advances in imaging technology, reduced mor-bidity and mortality in endovascular interventions, and faster convalescence following percutaneous therapy when compared to traditional operations. There is little doubt that with continued device development and refined image-guided technology, endo-vascular intervention will provide improved clinical outcomes and play an even greater role in the treatment of vascular disease.The


Surgery_Schwartz

Surgery_Schwartz. device development and refined image-guided technology, endo-vascular intervention will provide improved clinical outcomes and play an even greater role in the treatment of vascular disease.The technique of percutaneous access for both the diagnos-tic and therapeutic management of vascular disease has resulted in tremendous changes in the practice of several subspecialties, including interventional radiology, invasive cardiology, and vas-cular surgery. The development of catheter and endoscopic instru-mentation allows the vascular surgeon to operate via an intraor extraluminal route. Endovascular techniques are now able to treat the full spectrum of vascular pathology, including stenoses and occlusions resulting from several etiologies, aneurysmal pathol-ogy, and traumatic lesions. Many of these procedures have only recently been developed and, as such, have not been investigated Brunicardi_Ch23_p0897-p0980.indd 90327/02/19 4:13 PM 904SPECIFIC CONSIDERATIONSPART IIFigure 23-7. A.


Surgery_Schwartz

Surgery_Schwartz. these procedures have only recently been developed and, as such, have not been investigated Brunicardi_Ch23_p0897-p0980.indd 90327/02/19 4:13 PM 904SPECIFIC CONSIDERATIONSPART IIFigure 23-7. A. Antegrade femoral artery access. The needle is inserted just below the inguinal ligament in the common femoral artery whereby the guidewire is inserted in the ipsilateral super-ficial femoral artery. B. Brachial artery approach. The needle is inserted in a retrograde fashion in the brachial artery just above the antecubital fossa, whereby the guidewire is next inserted in the brachial artery.in a manner that would enable an accurate comparison with the more traditional methods of open surgical intervention. Long-term follow-up for these procedures is frequently lacking; how-ever, because of the potential to treat patients with decreased mortality and morbidity, endovascular skills and techniques are being adopted into mainstream vascular surgery.Needles and AccessNeedles are used to achieve


Surgery_Schwartz

Surgery_Schwartz. potential to treat patients with decreased mortality and morbidity, endovascular skills and techniques are being adopted into mainstream vascular surgery.Needles and AccessNeedles are used to achieve percutaneous vascular access. The size of the needle will be dictated by the diameter of the guide-wire used. Most often, an 18-gauge needle is used, as it will accept a 0.035-inch guidewire. A 21-gauge micropuncture nee-dle will accept a 0.018-inch guidewire. The most popular access needle is the Seldinger needle, which can be used for singleand double-wall puncture techniques.Femoral arterial puncture is the most common site for access. The common femoral artery (CFA) is punctured over the medial third of the femoral head, which is landmarked using flu-oroscopy. The single-wall puncture technique requires a sharp, beveled needle tip and no central stylet. The anterior wall of the vessel is punctured with the bevel of the needle pointing up, and pulsatile back-bleeding indicates an


Surgery_Schwartz

Surgery_Schwartz. technique requires a sharp, beveled needle tip and no central stylet. The anterior wall of the vessel is punctured with the bevel of the needle pointing up, and pulsatile back-bleeding indicates an intraluminal position. This method is most useful for graft punctures, patients with abnor-mal clotting profiles, or if thrombolytic therapy is anticipated. Once the needle assumes an intraluminal position, verified by pulsatile back-bleeding, the guidewire may be advanced. This is always passed gently and under fluoroscopic guidance to avoid subintimal dissection or plaque disruption. Double-wall puncture techniques are performed with a blunt needle that has a remov-able inner cannula. The introducer needle punctures both walls of the artery and is withdrawn until bleeding is obtained to confirm intraluminal position prior to advancing a guidewire. There can be troublesome bleeding from the posterior arterial wall punc-ture; therefore, single puncture techniques are preferred.Retrograde


Surgery_Schwartz

Surgery_Schwartz. intraluminal position prior to advancing a guidewire. There can be troublesome bleeding from the posterior arterial wall punc-ture; therefore, single puncture techniques are preferred.Retrograde femoral access is the most common arte-rial access technique (Fig. 23-7). The advantages of this technique include the size and fixed position of the CFA, as well as the relative ease of compression against the femoral head at the end of the procedure. Care should be taken to avoid puncturing the external iliac artery above the inguinal ligament because this can result in retroperitoneal hemor-rhage secondary to ineffective compression of the puncture site. Likewise, puncturing too low, at or below the CFA bifurcation, can result in thrombosis or pseudoaneurysm for-mation of the superficial femoral artery (SFA) or profunda femoris artery (PFA). Antegrade femoral access is more dif-ficult than retrograde femoral access, and there is a greater tendency to puncture the SFA, but it is invaluable


Surgery_Schwartz

Surgery_Schwartz. artery (SFA) or profunda femoris artery (PFA). Antegrade femoral access is more dif-ficult than retrograde femoral access, and there is a greater tendency to puncture the SFA, but it is invaluable when the aortic bifurcation cannot be traversed or when devices are not long enough to reach a lesion from a contralateral femo-ral access approach. Occasionally, when the distal aorta or bilateral iliac arteries are inaccessible because of the extent of atherosclerotic lesions, scarring, or presence of bypass conduits, the brachial artery must be used to obtain access for diagnostic and therapeutic interventions. The left bra-chial artery is punctured because this avoids the origin of the carotid artery and thus decreases the risk of catheter-related emboli to the brain. The artery is accessed with a micropunc-ture needle just proximal to the antecubital crease. The use of brachial access is associated with a higher risk of thrombosis and nerve injuries than femoral


Surgery_Schwartz

Surgery_Schwartz. The artery is accessed with a micropunc-ture needle just proximal to the antecubital crease. The use of brachial access is associated with a higher risk of thrombosis and nerve injuries than femoral access.GuidewiresGuidewires are used to introduce, position, and exchange cath-eters. A guidewire generally has a flexible and stiff end. In general, only the flexible end of the guidewire is placed in the vessel. All guidewires are composed of a stiff inner core and an outer tightly coiled spring that allows a catheter to track over the guidewire. There are five essential characteristics of guidewires: size, length, stiffness, coating, and tip configuration.Guidewires come in different maximum transverse diam-eters, ranging from 0.011 to 0.038 inches. For most aortoiliac procedures, a 0.035-inch wire is most commonly used, whereas the smaller diameter 0.018-inch guidewires are reserved for selective small vessel angiography such as infrageniculate or carotid lesions. In addition to


Surgery_Schwartz

Surgery_Schwartz. wire is most commonly used, whereas the smaller diameter 0.018-inch guidewires are reserved for selective small vessel angiography such as infrageniculate or carotid lesions. In addition to diameter size, guidewires come in varying lengths, usually ranging from 180 to 260 cm in length. Increasing the length of the wire always makes it more difficult to handle and increases the risk of contamination. While per-forming a procedure, it is important to maintain the guidewire across the lesion until the completion arteriogram has been sat-isfactorily completed.The stiffness of the guidewire is also an important charac-teristic. Stiff wires allow for passage of large aortic stent graft devices without kinking. They are also useful when trying to perform sheath or catheter exchanges around a tortuous artery. An example of a stiff guidewire is the Amplatz wire. Hydro-philic coated guidewires, such as the Glidewire, have become invaluable tools for assisting in difficult catheterizations. The


Surgery_Schwartz

Surgery_Schwartz. artery. An example of a stiff guidewire is the Amplatz wire. Hydro-philic coated guidewires, such as the Glidewire, have become invaluable tools for assisting in difficult catheterizations. The coating is primed by bathing the guidewire in saline solution. The slippery nature of this guidewire along with its torque capa-bility significantly facilitate in difficult catheterizations. Guide-wires also come in various tip configurations. Angled tip wires like the angled Glidewire can be steered to manipulate a catheter across a tight stenosis or to select a specific branch of a vessel. The Rosen wire has a soft curled end, which makes it ideal for renal artery stenting. The soft curl of this wire prevents it from perforating small renal branch vessels.Brunicardi_Ch23_p0897-p0980.indd 90427/02/19 4:13 PM 905ARTERIAL DISEASECHAPTER 23Figure 23-8. All percutaneous endovascular procedures are per-formed through an introducer sheath (large arrow), which pro-vides an access conduit from


Surgery_Schwartz

Surgery_Schwartz. 4:13 PM 905ARTERIAL DISEASECHAPTER 23Figure 23-8. All percutaneous endovascular procedures are per-formed through an introducer sheath (large arrow), which pro-vides an access conduit from skin to intravascular compartment. The sheath also acts to protect the vessel from injury as guidewires (small arrows) and catheters are introduced.Hemostatic SheathsThe hemostatic sheath is a device through which endovascular procedures are performed. The sheath acts to protect the vessel from injury as wires and catheters are introduced (Fig. 23-8). A one-way valve prevents bleeding through the sheath, and a side-port allows contrast or heparin flushes to be administered during the procedure. Sheaths are sized by their inner diameter. The most commonly used sheaths for percutaneous access have a 5to 9-French inner diameter, but with open surgical exposure of the CFA, sheaths as large as 26 French can be introduced. Sheaths also vary in length, and long sheaths are available so that interventions


Surgery_Schwartz

Surgery_Schwartz. 9-French inner diameter, but with open surgical exposure of the CFA, sheaths as large as 26 French can be introduced. Sheaths also vary in length, and long sheaths are available so that interventions remote from the site of arterial access can be performed.CathetersA wide variety of catheters exist that differ primarily in the con-figuration of the tip. The multiple shapes permit access to ves-sels of varying dimensions and angulations. Catheters are used to perform angiography and protect the passage of balloons and stents, and they can be used to direct the guidewire through tight stenoses or tortuous vessels.Figure 23-9. A. An artery with luminal narrowing caused by plaque. B. A balloon angioplasty catheter is positioned within the diseased artery, which is inflated to enlarge the intravascular channel. C. The plaque is compressed with widened flow lumen as the result of balloon angioplasty.Angioplasty BalloonsAngioplasty balloons differ primarily in their length and diam-eter, as


Surgery_Schwartz

Surgery_Schwartz. channel. C. The plaque is compressed with widened flow lumen as the result of balloon angioplasty.Angioplasty BalloonsAngioplasty balloons differ primarily in their length and diam-eter, as well as the length of the catheter shaft. As balloon technology has advanced, lower profiles have been manufac-tured (i.e., the size that the balloon assumes upon deflation). Balloons are used to perform angioplasty on vascular stenoses, to deploy stents, and to assist with additional expansion after insertion of self-expanding stents (Fig. 23-9). Besides length and diameter, operators need to be familiar with several other balloon characteristics. Noncompliant and low-compliance balloons tend to be inflated to their preset diameter and offer greater dilating force at the site of stenosis. Low-compliance balloons are the mainstay for peripheral intervention. Lower profile balloons are less likely to get caught during passage through stents and are easier to pull out of sheaths. Under fluoroscopic


Surgery_Schwartz

Surgery_Schwartz. balloons are the mainstay for peripheral intervention. Lower profile balloons are less likely to get caught during passage through stents and are easier to pull out of sheaths. Under fluoroscopic guidance, balloon inflation is performed until the waist of the atherosclerotic lesion disappears and the balloon is at the full profile. The duration of balloon inflation and pres-sures used for the angioplasty depend on the indication for the intervention and the location and characteristics of the lesion being treated. Frequently, several inflations are required to achieve a full profile of the balloon. Occasionally, a lower pro-file balloon is needed to predilate the tight stenosis so that the selected balloon catheter can cross the lesion. After inflation, most balloons do not regain their preinflation diameter and assume a larger profile. Trackability, pushability, and cross-ability of the balloon should all be considered when choosing a particular balloon. Lastly, shoulder length is an


Surgery_Schwartz

Surgery_Schwartz. diameter and assume a larger profile. Trackability, pushability, and cross-ability of the balloon should all be considered when choosing a particular balloon. Lastly, shoulder length is an important characteristic to consider when selecting a balloon because of the potential to cause injury during performance of PTA in adjacent arterial segments. There is always risk of causing dis-section or rupture during PTA; thus, a completion angiogram is performed while the wire is still in place. Leaving the wire in place provides access for repeating the procedure, placing a stent or stent graft if warranted.StentsVascular stents are commonly used after an inadequate angio-plasty with dissection or elastic recoil of an arterial stenosis. They serve to buttress collapsible vessels and help prevent atherosclerotic restenosis. Appropriate indications for primary stenting of a lesion without an initial trial of angioplasty alone are evolving in manners that are dependent on the extent and site of


Surgery_Schwartz

Surgery_Schwartz. atherosclerotic restenosis. Appropriate indications for primary stenting of a lesion without an initial trial of angioplasty alone are evolving in manners that are dependent on the extent and site of the lesion. Stents are manufactured from a variety of metals including stainless steel, tantalum, cobalt-based alloy, Brunicardi_Ch23_p0897-p0980.indd 90527/02/19 4:13 PM 906SPECIFIC CONSIDERATIONSPART IIFigure 23-10. Self-expanding stents are made of tempered stainless steel or nitinol, an alloy of nickel and titanium, and are restrained when folded inside a delivery catheter. After being released from the restraining catheter, the self-expanding stents will expand to a final diameter that is determined by stent geometry, hoop strength, and vessel size.Figure 23-11. In a balloon-expandable stent, the stent is pre-mounted on a balloon catheter. The balloon stretches the stent members beyond their elastic limit. The stent is deployed by full balloon expansion. This type of stent has a


Surgery_Schwartz

Surgery_Schwartz. stent, the stent is pre-mounted on a balloon catheter. The balloon stretches the stent members beyond their elastic limit. The stent is deployed by full balloon expansion. This type of stent has a higher degree of crush resistance when compared to self-expanding stents, which is ideal for short-segment calcified ostial lesions.and nitinol. Vascular stents are classified into two basic categories: balloon-expandable stents and self-expanding stents.Self-expanding stents (Fig. 23-10) are deployed by retract-ing a restraining sheath and usually consist of Elgiloy (a cobalt, chromium, nickel alloy) or nitinol (a shape memory alloy com-posed of nickel and titanium), the latter of which will contract and assume a heat-treated shape above a transition temperature that depends on the composition of the alloy. Self-expanding stents will expand to a final diameter that is determined by stent geometry, hoop strength, and vessel size. The self-expanding stent is mounted on a central shaft and is


Surgery_Schwartz

Surgery_Schwartz. of the alloy. Self-expanding stents will expand to a final diameter that is determined by stent geometry, hoop strength, and vessel size. The self-expanding stent is mounted on a central shaft and is placed inside an outer sheath. It relies on a mechanical spring-like action to achieve expansion. With deployment of these stents, there is some degree of foreshortening that has to be taken into account when choosing the area of deployment. In this way, self-expanding stents are more difficult to place with absolute precision. There are several advantages related to self-expanding stents. Self-expanding stents generally come in longer lengths than balloon-expandable stents and are therefore used to treat long and tortuous lesions. Their ability to continually expand after deliv-ery allows them to accommodate adjacent vessels of different size. This makes these stents ideal for placement in the internal carotid artery. These stents are always oversized by 1 to 2 mm relative to the largest


Surgery_Schwartz

Surgery_Schwartz. to accommodate adjacent vessels of different size. This makes these stents ideal for placement in the internal carotid artery. These stents are always oversized by 1 to 2 mm relative to the largest diameter of normal vessel adjacent to the lesion in order to prevent immediate migration.Balloon-expandable stents are usually composed of stain-less steel, mounted on an angioplasty balloon, and deployed by balloon inflation (Fig. 23-11). They can be manually placed on a chosen balloon catheter or obtained premounted on a balloon catheter. The capacity of a balloon-expandable stent to shorten in length during deployment depends on both stent geometry and the final diameter to which the balloon is expanded. These stents are more rigid and are associated with a shorter time to complete endothelialization. They are often of limited flexibility and have a higher degree of crush resistance when compared to self-expanding stents. This makes them ideal for short-segment lesions, especially those


Surgery_Schwartz

Surgery_Schwartz. They are often of limited flexibility and have a higher degree of crush resistance when compared to self-expanding stents. This makes them ideal for short-segment lesions, especially those that involve the ostia such as proximal common iliac or renal artery stenosis.An important area of evolution in endovascular therapy in recent years is the development of drug-eluting stents (DES). These stents are usually composed of nitinol and have vari-ous anti-inflammatory drugs bonded to them. Over time, the stents release the drug into the surrounding arterial wall and help prevent restenosis. Numerous randomized controlled trials have proven their benefit in coronary arteries.9 Clinical studies have similarly proved early efficacy of DES in the treatment of peripheral arterial disease.10Stent GraftsThe combination of a metal stent covered with fabric gave birth to the first stent grafts. Covered stents have been designed with either a surrounding PTFE or polyester fabric and have been used


Surgery_Schwartz

Surgery_Schwartz. combination of a metal stent covered with fabric gave birth to the first stent grafts. Covered stents have been designed with either a surrounding PTFE or polyester fabric and have been used predominantly for treatment of traumatic vascular lesions, including arterial disruption and arteriovenous fistulas (Fig. 23-12). However, these devices may well find a growing role in treatment of iliac or femoral arterial occlusive disease as well as popliteal aneurysms.Endovascular aneurysm repair using the concept of stent grafts was initiated by Parodi in 1991.11 Since that time, a large number of endografts have been inserted under the auspice of clinical trials initially and now as Food and Drug Administra-tion (FDA)–approved devices. Currently there are more than Brunicardi_Ch23_p0897-p0980.indd 90627/02/19 4:13 PM 907ARTERIAL DISEASECHAPTER 23Figure 23-12. A stent graft is a metal stent covered with fabric that is com-monly used for aneurysm exclusion.eight FDA-approved endovascular


Surgery_Schwartz

Surgery_Schwartz. 90627/02/19 4:13 PM 907ARTERIAL DISEASECHAPTER 23Figure 23-12. A stent graft is a metal stent covered with fabric that is com-monly used for aneurysm exclusion.eight FDA-approved endovascular devices for abdominal aortic aneurysm repair. In general, majority of these devices require that patients have an infrarenal aneurysm with at least a 15-mm proximal aortic neck below the renal arteries and not greater than 60° of angulation. For those patients with associated com-mon iliac artery aneurysmal disease, endovascular treatment can be achieved by initial coil embolization of the ipsilateral hypogastric artery with extension of the endovascular device into the external iliac artery. Newer generation devices with branched endograft can be deployed in the internal iliac artery while maintain in-line flow from the common iliac to exter-nal iliac artery to exclude the common iliac artery aneurysm. Recent clinical trials have demonstrated clinical efficacy of fenestrated aortic endograft


Surgery_Schwartz

Surgery_Schwartz. in-line flow from the common iliac to exter-nal iliac artery to exclude the common iliac artery aneurysm. Recent clinical trials have demonstrated clinical efficacy of fenestrated aortic endograft in treating aneurysm involving the visceral segment of the abdominal aorta.12 The FDA has simi-larly approved several thoracic endograft devices for the treat-ment of descending thoracic aortic aneurysm. Clinical studies have similarly demonstrated durability and efficacy of thoracic aortic devices in patients with traumatic aortic transections and aortic dissections.13CAROTID ARTERY DISEASEAtherosclerotic occlusive plaque is by far the most common pathology seen in the carotid artery bifurcation. Thirty percent to 60% of all ischemic strokes are related to atherosclerotic carotid bifurcation occlusive disease. In the following section, we first focus our discussion on the clinical presentation, diagnosis, and management—including medical therapy, surgical carotid end-arterectomy, and


Surgery_Schwartz

Surgery_Schwartz. occlusive disease. In the following section, we first focus our discussion on the clinical presentation, diagnosis, and management—including medical therapy, surgical carotid end-arterectomy, and stenting—of atherosclerotic carotid occlusive disease. In the second part of the section, we provide a review on other less common nonatherosclerotic diseases involving the extracranial carotid artery, including kink and coil, fibromuscu-lar dysplasia, arterial dissection, aneurysm, radiation arteritis, Takayasu’s arteritis, and carotid body tumor.Epidemiology and Etiology of Carotid Occlusive DiseaseApproximately 700,000 Americans suffer a new or recur-rent stroke each year.14 Eighty-five percent of all strokes are ischemic, and 15% are hemorrhagic. Hemorrhagic strokes are caused by head trauma or spontaneous disruption of intracere-bral blood vessels. Ischemic strokes are due to hypoperfusion from arterial occlusion or, less commonly, to decreased flow resulting from proximal arterial


Surgery_Schwartz

Surgery_Schwartz. or spontaneous disruption of intracere-bral blood vessels. Ischemic strokes are due to hypoperfusion from arterial occlusion or, less commonly, to decreased flow resulting from proximal arterial stenosis and poor collateral network. Common causes of ischemic strokes are cardiogenic emboli in 35%, carotid artery disease in 30%, lacunar in 10%, miscellaneous in 10%, and idiopathic in 15%.19 The term cere-brovascular accident is often used interchangeably to refer to an ischemic stroke. A transient ischemic attack (TIA) is defined as a temporary focal cerebral or retinal hypoperfusion state that resolves spontaneously within 24 hours after its onset. However, the majority of TIAs resolve within minutes, and longer-lasting neurologic deficits more likely represent a stroke. Recently, the term brain attack has been coined to refer to an acute stroke or TIA, denoting the condition as a medical emergency requiring immediate attention, similar to a heart attack.Stroke due to carotid


Surgery_Schwartz

Surgery_Schwartz. the term brain attack has been coined to refer to an acute stroke or TIA, denoting the condition as a medical emergency requiring immediate attention, similar to a heart attack.Stroke due to carotid bifurcation occlusive disease is usu-ally caused by atheroemboli (Fig. 23-13). The carotid bifurca-tion is an area of low flow velocity and low shear stress. As the blood circulates through the carotid bifurcation, there is separa-tion of flow into the low-resistance internal carotid artery and the high-resistance external carotid artery. Characteristically, atherosclerotic plaque forms in the outer wall opposite to the flow divider (Fig. 23-14). Atherosclerotic plaque formation is complex, beginning with intimal injury, platelet deposition, smooth muscle cell proliferation, and fibroplasia, and leading to subsequent luminal narrowing. With increasing degree of ste-nosis in the internal carotid artery, flow becomes more turbu-lent, and the risk of atheroembolization escalates. The severity


Surgery_Schwartz

Surgery_Schwartz. leading to subsequent luminal narrowing. With increasing degree of ste-nosis in the internal carotid artery, flow becomes more turbu-lent, and the risk of atheroembolization escalates. The severity of stenosis is commonly divided into three categories accord-ing to the luminal diameter reduction: mild (<50%), moderate (50–69%), and severe (70–99%). Severe carotid stenosis is a strong predictor for stroke.15 In turn, a prior history of neuro-logic symptoms (TIA or stroke) is an important determinant for recurrent ipsilateral stroke. The risk factors for the development of carotid artery bifurcation disease are similar to those causing atherosclerotic occlusive disease in other vascular beds. Increas-ing age, male gender, hypertension, tobacco smoking, diabetes mellitus, homocysteinemia, and hyperlipidemia are well-known predisposing factors for the development of atherosclerotic occlusive disease.Clinical Manifestations of Cerebral IschemiaTIA is a focal loss of neurologic function,


Surgery_Schwartz

Surgery_Schwartz. and hyperlipidemia are well-known predisposing factors for the development of atherosclerotic occlusive disease.Clinical Manifestations of Cerebral IschemiaTIA is a focal loss of neurologic function, lasting for less than 24 hours. Crescendo TIAs refer to a syndrome comprising repeated TIAs within a short period of time that is character-ized by complete neurologic recovery in between. At a minimum, the term should probably be reserved for those with either daily events or multiple resolving attacks within 24 hours. Brunicardi_Ch23_p0897-p0980.indd 90727/02/19 4:13 PM 908SPECIFIC CONSIDERATIONSPART IIFigure 23-14. A. The carotid bifurcation is an area of low flow velocity and low shear stress. As the blood circulates through the carotid bifurcation, there is separation of flow into the low-resistance internal carotid artery and the high-resistance external carotid artery. B. The carotid atherosclerotic plaque typi-cally forms in the outer wall opposite to the flow divider due in


Surgery_Schwartz

Surgery_Schwartz. low-resistance internal carotid artery and the high-resistance external carotid artery. B. The carotid atherosclerotic plaque typi-cally forms in the outer wall opposite to the flow divider due in part to the effect of the low shear stress region, which also creates a tran-sient reversal of flow during the cardiac cycle.InternalcarotidarteryEmboliUlcerPlaqueCommoncarotidarteryExternalcarotidarterySuperiorthyroidarteryFigure 23-13. Stroke due to carotid bifurcation occlusive disease is usually caused by atheroemboli arising from the internal carotid artery, which provides the majority of blood flow to the cerebral hemisphere. With increasing degree of stenosis in the carotid artery, flow becomes more turbulent, and the risk of atheroembolization escalates.BASectional viewLow-shearregionHigh-shearregionHemodynamic TIAs represent focal cerebral events that are aggravated by exercise or hemodynamic stress and typically occur after short bursts of physical activity, postprandially, or


Surgery_Schwartz

Surgery_Schwartz. TIAs represent focal cerebral events that are aggravated by exercise or hemodynamic stress and typically occur after short bursts of physical activity, postprandially, or after getting out of a hot bath. It is implied that these are due to severe extracranial disease and poor intracranial collateral recruitment. Reversible ischemic neurologic deficits refer to ischemic focal neurologic symptoms lasting longer than 24 hours but resolv-ing within 3 weeks. When a neurologic deficit lasts longer than 3 weeks, it is considered a completed stroke. Stroke in evolution refers to progressive worsening of the neurologic deficit, either linearly over a 24-hour period or interspersed with transient periods of stabilization and/or partial clinical improvement.Patients who suffer cerebrovascular accidents typically present with three categories of symptoms including ocular symptoms, sensory/motor deficit, and/or higher cortical dys-function. The common ocular symptoms associated with extra-cranial


Surgery_Schwartz

Surgery_Schwartz. typically present with three categories of symptoms including ocular symptoms, sensory/motor deficit, and/or higher cortical dys-function. The common ocular symptoms associated with extra-cranial carotid artery occlusive disease include amaurosis fugax and presence of Hollenhorst plaques. Amaurosis fugax, com-monly referred to as transient monocular blindness, is a tempo-rary loss of vision in one eye that patients typically describe as a window shutter coming down or grey shedding of the vision. This partial blindness usually lasts for a few minutes and then resolves. Most of these phenomena (>90%) are due to embolic occlusion of the main artery or the upper or lower divisions. Monocular blindness progressing over a 20-minute period sug-gests a migrainous etiology. Occasionally, the patient will recall no visual symptoms while the optician notes a yellowish plaque within the retinal vessels, which is also known as Hollenhorst plaque. These plaques are frequently derived from


Surgery_Schwartz

Surgery_Schwartz. the patient will recall no visual symptoms while the optician notes a yellowish plaque within the retinal vessels, which is also known as Hollenhorst plaque. These plaques are frequently derived from cholesterol embolization from the carotid bifurcation and warrant further investigation. Additionally, several ocular symptoms may be caused by microembolization from extracranial carotid dis-eases including monocular visual loss due to retinal artery or optic nerve ischemia, the ocular ischemia syndrome, and visual field deficits secondary to cortical infarction and ischemia of the optic tracts. Typical motor and/or sensory symptoms asso-ciated with cerebrovascular accidents are lateralized or focal neurologic deficits. Ischemic events tend to have an abrupt onset, with the severity of the insult being apparent from the onset and not usually associated with seizures or paresthesia. In contrast, they represent loss or diminution of neurologic func-tion. Furthermore, motor or sensory


Surgery_Schwartz

Surgery_Schwartz. the insult being apparent from the onset and not usually associated with seizures or paresthesia. In contrast, they represent loss or diminution of neurologic func-tion. Furthermore, motor or sensory deficits can be unilateral or Brunicardi_Ch23_p0897-p0980.indd 90827/02/19 4:14 PM 909ARTERIAL DISEASECHAPTER 23bilateral, with the upper and lower limbs being variably affected depending on the site of the cerebral lesion. The combination of a motor and sensory deficit in the same body territory is sug-gestive of a cortical thromboembolic event as opposed to lacu-nar lesions secondary to small vessel disease of the penetrating arterioles. However, a small proportion of the latter may present with a sensorimotor stroke secondary to small vessel occlusion within the posterior limb of the internal capsule. Pure sensory and pure motor strokes and those strokes where the weakness affects one limb only or does not involve the face are more typically seen with lacunar as opposed to cortical


Surgery_Schwartz

Surgery_Schwartz. capsule. Pure sensory and pure motor strokes and those strokes where the weakness affects one limb only or does not involve the face are more typically seen with lacunar as opposed to cortical infarction. A number of higher cortical functions, including speech and language disturbances, can be affected by thromboembolic phe-nomena from the carotid artery, with the most important clinical example for the dominant hemisphere being dysphasia or apha-sia and visuospatial neglect being an example of nondominant hemisphere injury.Diagnostic EvaluationDuplex ultrasonography is the most widely used screening tool to evaluate for atherosclerotic plaque and stenosis of the extracranial carotid artery. It is also commonly used to monitor patients serially for progression of disease or after intervention (carotid endarterectomy or angioplasty). Duplex ultrasound of the carotid artery combines B-mode gray-scale imaging and Doppler waveform analysis. Characterization of the carotid plaque on


Surgery_Schwartz

Surgery_Schwartz. (carotid endarterectomy or angioplasty). Duplex ultrasound of the carotid artery combines B-mode gray-scale imaging and Doppler waveform analysis. Characterization of the carotid plaque on gray-scale imaging provides useful information about its composition. However, there are currently no universal rec-ommendations that can be made based solely on the sonographic appearance of the plaque. On the other hand, criteria have been developed and well refined for grading the degree of carotid ste-nosis based primarily on Doppler-derived velocity waveforms.The external carotid artery has a high-resistance flow pat-tern with a sharp systolic peak and a small amount of flow in diastole. In contrast, a normal internal carotid artery will have a low-resistance flow pattern with a broad systolic peak and a large amount of flow during diastole. The flow pattern in the common carotid artery resembles that in the internal carotid artery, as 80% of the flow is directed to the internal carotid artery,


Surgery_Schwartz

Surgery_Schwartz. and a large amount of flow during diastole. The flow pattern in the common carotid artery resembles that in the internal carotid artery, as 80% of the flow is directed to the internal carotid artery, with waveforms that have broad systolic peaks and mod-erate amount of flow during diastole. Conventionally, velocity measurements are recorded in the common, external, carotid bulb, and the proximal, mid, and distal portions of the internal carotid artery. Characteristically, the peak systolic velocity is increased at the site of the vessel stenosis. The end-diastolic velocity is increased with greater degree of stenosis. In addition, stenosis of the internal carotid artery can lead to color shifts with color mosaics indicating a poststenotic turbulence. Dampening of the Doppler velocity waveforms is typically seen in areas distal to severe carotid stenosis where blood flow is reduced. It is well known that occlusion of the ipsilateral internal carotid artery can lead to a “falsely”


Surgery_Schwartz

Surgery_Schwartz. waveforms is typically seen in areas distal to severe carotid stenosis where blood flow is reduced. It is well known that occlusion of the ipsilateral internal carotid artery can lead to a “falsely” elevated velocity on the contralat-eral side due to an increase in compensatory blood flow. In the presence of a high-grade stenosis or occlusion of the internal carotid artery, the ipsilateral common carotid artery displays high flow resistance waveforms, similar to those seen in the external carotid artery. If there is a significant stenosis in the proximal common carotid artery, its waveforms may be damp-ened with low velocities.The Doppler grading systems of carotid stenosis were initially established by comparison to angiographic findings of disease. Studies have shown variability in the measurements of the duplex properties by different laboratories, as well as hetero-geneity in the patient population, study design, and techniques. One the most commonly used classifications was


Surgery_Schwartz

Surgery_Schwartz. the measurements of the duplex properties by different laboratories, as well as hetero-geneity in the patient population, study design, and techniques. One the most commonly used classifications was established at the University of Washington School of Medicine in Seattle, Washington.16 Diameter reduction of 50% to 79% is defined by peak systolic velocity greater than 125 cm/s with extensive spectral broadening. For stenosis in the range of 80% to 99%, the peak systolic velocity is greater than 125 cm/s, and peak diastolic velocity is greater than 140 cm/s. The ratio of inter-nal carotid to common carotid artery peak systolic velocity has also been part of various ultrasound diagnostic classifications. A ratio greater than 4 is a great predictor of angiographic ste-nosis of 70% to 99%. A multispecialty consensus panel has developed a set of criteria for grading carotid stenosis by duplex examination (Table 23-3).MRA is increasingly being used to evaluate for athero-sclerotic carotid


Surgery_Schwartz

Surgery_Schwartz. multispecialty consensus panel has developed a set of criteria for grading carotid stenosis by duplex examination (Table 23-3).MRA is increasingly being used to evaluate for athero-sclerotic carotid occlusive disease and intracranial circulation. MRA is noninvasive and does not require iodinated contrast agents. MRA uses phase contrast or time-of-flight, with either two-dimensional or three-dimensional data sets for greater accu-racy. Three-dimensional contrast-enhanced MRA allows data to be obtained in coronal and sagittal planes with improved image qualities due to shorter study time. In addition, the new MRA techniques allow for better reformation of images in vari-ous planes to allow better grading of stenosis. There have been numerous studies comparing the sensitivity and specificity of Table 23-3Carotid duplex ultrasound criteria for grading internal carotid artery stenosisDEGREE OF STENOSIS (%)ICA PSV (CM/S)ICA/CCA PSV RATIOICA EDV (CM/S)PLAQUE ESTIMATE


Surgery_Schwartz

Surgery_Schwartz. and specificity of Table 23-3Carotid duplex ultrasound criteria for grading internal carotid artery stenosisDEGREE OF STENOSIS (%)ICA PSV (CM/S)ICA/CCA PSV RATIOICA EDV (CM/S)PLAQUE ESTIMATE (%)aNormal<125<2.0<40None<50<125<2.0<40<5050–69125–2302.0–4.040–100≥50≥70 to less than near occlusion>230>4.0>100≥50Near occlusionHigh, low, or not detectedVariableVariableVisibleTotal occlusionNot detectedNot applicableNot detectedVisible, no lumenaPlaque estimate (diameter reduction) with gray-scale and color Doppler ultrasound.CCA = common carotid artery; EDV = end-diastolic velocity; ICA = internal carotid artery; PSV = peak systolic velocity.Brunicardi_Ch23_p0897-p0980.indd 90927/02/19 4:14 PM 910SPECIFIC CONSIDERATIONSPART IIFigure 23-15. A. Carotid computed tomography angiography is a valuable imaging modality that can provide a three-dimensional image reconstruction with high image resolution. A carotid artery occlusion is noted in the internal carotid artery B. The entire segment of


Surgery_Schwartz

Surgery_Schwartz. imaging modality that can provide a three-dimensional image reconstruction with high image resolution. A carotid artery occlusion is noted in the internal carotid artery B. The entire segment of extracranial carotid artery is visualized from the thoracic compartment to the base of skull.Figure 23-16. A carotid angiogram reveals an ulcerated carotid plaque (arrow) in the proximal internal carotid artery, which also resulted in a high-grade internal carotid artery stenosis.MRA imaging for carotid disease to duplex and selective con-trast angiography.17 Magnetic resonance imaging (MRI) of the brain is essential in the assessment of acute stroke patients. MRI with diffusion-weighted imaging can differentiate areas of acute ischemia, areas still at risk for ischemia (penumbra), and chronic cerebral ischemic changes. However, computed tomography (CT) imaging remains the most expeditious test in the evaluation of acute stroke patients to rule out intracerebral hemorrhage. Recently,


Surgery_Schwartz

Surgery_Schwartz. cerebral ischemic changes. However, computed tomography (CT) imaging remains the most expeditious test in the evaluation of acute stroke patients to rule out intracerebral hemorrhage. Recently, multidetector CTA has gained increasing popularity in the evaluation of carotid disease.18 This imaging modality can provide volume rendering, which allows rotation of the object with accurate anatomic structures from all angles (Fig. 23-15). The advantages of CTA over MRA include faster data acquisition time and better spatial resolution. However, grading of carotid stenosis by CTA requires further validation at the time of this writing before it can be widely applied.Historically, DSA has been the gold standard test to evalu-ate the extraand intracranial circulation (Fig. 23-16). This is an invasive procedure, typically performed via a transfemoral puncture, and involves selective imaging of the carotid and ver-tebral arteries using iodinated contrast. The risk of stroke during cerebral