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Manual of Vascular Surgery
AK Khanna, Puneet
CHAPTER 1:
Introduction to Peripheral Arterial Disease
CHAPTER 2:
Clinical Examination of a Vascular Case
PHYSICAL EXAMINATION
Signs of Advanced Ischemia
THE VENOUS SYSTEM
Tests for Varicose Veins
LYMPHATIC DISEASE
CHAPTER 3:
Vascular Imaging
MAGNETIC RESONANCE ANGIOGRAPHY (MRA)
Unenhanced Angiography
Limitations of Unenhanced MRA
Other Limitations Include
CONTRAST ENHANCED MRA
Advantages of Contrast Enhanced MRA
PERIPHERAL MR ANGIOGRAPHY
ABDOMINAL AND RENAL ANGIOGRAPHY
MR VENOGRAPHY OF LOWER LIMBS
CT ANGIOGRAPHY
Indications for MSCT Angiography
Visceral Angiography
STRENGTHS AND LIMITATIONS OF CT ANGIOGRAPHY (CTA) IN COMPARISON TO OTHER VASCULAR IMAGING MODALITIES
CTA Versus MRA
CTA Versus Catheter Angiography
SPECIFIC APPLICATIONS OF CTA
Imaging of Mesenteric Vasculature and Bowel
Peripheral Arterial System
Peripheral Arteriography
Venography
CHAPTER 4:
Surgical Exposure of Vessels
EXPOSURE OF THE CAROTID ARTERY
Surgical Anatomy
TECHNIQUE OF CAROTID EXPOSURE
Position
Skin Incision
EXPOSURE OF ABDOMINAL AORTA AND ILIAC ARTERIES
Surgical Anatomy
Transperitoneal Infrarenal Aortic Exposure
TRANSPERITONEAL EXPOSURE OF ILIAC ARTERIES
Exposure of Right External Iliac Artery
Exposure of Left External Iliac Artery
RETROPERITONEAL EXPOSURE OF ABDOMINAL AORTA
Retroperitoneal Infrarenal Aortic Exposure
RETROPERITONEAL EXPOSURE OF ILIAC ARTERIES
Exposure of External Iliac Artery
Extraperitoneal Exposure of Iliac Axis
COMBINED ILIAC AND FEMORAL EXPOSURES
Separate Abdominal and Thigh Incisions
Combined Abdominal and Thigh Incision
EXPOSURE OF SUBCLAVIAN ARTERY
Surgical Anatomy
EXPOSURE OF LEFT SUBCLAVIAN ARTERY
EXPOSURE OF RIGHT SUBCLAVIAN ARTERY
EXPOSURE OF SUBCLAVIAN ARTERY WITH RESECTION OF THE CLAVICLE
VARIANT TECHNIQUES OF SUBCLAVIAN ARTERY EXPOSURE
EXPOSURE OF AXILLARY ARTERY
Surgical Anatomy
Techniques of Exposure of Axillary Artery
Anterior Approach
Subclavicular Horizontal Approach
Deltopectoral Approach
Combined Approach: Deltopectoral-subclavicular
Tanspectoral Approach
Subpectoral-axillary Approach
EXPOSURE OF BRACHIAL ARTERY
Surgical Anatomy
Exposure of Upper Half of Brachial Artery
Exposure of Distal Brachial Artery and its Bifurcation
EXPOSURE OF RADIAL AND ULNAR ARTERIES
Surgical Anatomy
Exposure of Radial Artery
Exposure of Ulnar Artery
EXPOSURE OF THE FEMORAL ARTERY
Surgical Anatomy
Exposure of Femoral Artery in Femoral Triangle
Exposure of Superficial Femoral Artery in the Adductor Canal
EXPOSURE OF THE POPLITEAL ARTERY
Surgical Anatomy
MEDIAL APPROACH TO PROXIMAL POPLITEAL ARTERY
Medial Approach to Entire Popliteal Artery
Medial Approach to Distal Popliteal Artery
Posterior Approach to Popliteal Artery
EXPOSURE OF POSTERIOR TIBIAL ARTERY
EXPOSURE OF TERMINAL POSTERIOR TIBIAL ARTERY
EXPOSURE OF ANTERIOR TIBIAL ARTERY
Exposure of Proximal Segment
Exposure of Distal Segment
COMBINED EXPOSURE OF DISTAL POPLITEAL ARTERY AND ITS TRIFURCATION
Medial Exposure
Lateral or Transfibular Exposure
EXPOSURE OF THE DORSALIS PEDIS ARTERY
Surgical Anatomy
Procedure of Dorsalis Pedis Artery Exposure
CHAPTER 5:
Vascular Sutures and Anastomoses
CHAPTER 6:
Endovascular Interventions– Surgeon's Perspective
SPECTRUM OF ENDOVASCULAR INTERVENTIONS
Vascular Access
Stent Retrieval Devices
Intervention Hardware
Preprocedural Details
Procedural Details
Renal Artery Interventions
Aortoiliac Intervention
Femoral Artery Interventions
Carotid Artery Stenting
CONCLUSION
CHAPTER 7:
Management of Vascular Trauma
INTRODUCTION
PATHOPHYSIOLOGY
Patterns of Vascular Injury
Diagnosis
Plain Radiography
Ankle Brachial Pressure Index (ABI)
Color-flow Duplex Ultrasonography (CD)
Angiography
Management
Operative Strategy
Shunting
Intraoperative Angiography
Damage Control
Primary Amputation
COMPARTMENT SYNDROME
CHAPTER 8:
Acute Arterial Ischemia
PATHOPHYSIOLOGY
Reperfusion Injury
Clinical Features of Limb Ischemia
Laboratory Assessment
Treatment
Embolectomy
Postoperative Anticoagulation
Fasciotomy
Fibrinolytic Therapy
Changing Pattern of Limb Ischemia
CONCLUSION
CHAPTER 9:
Chronic Arterial Insufficiency
CONLCUSIONS
CHAPTER 10:
Lower-extremity Atherosclerotic Arterial Disease
CLINICAL DETAILS
Diagnostic Evaluation
INVESTIGATIONS
Radiograph
Ultrasound
CT Scan
MRI
Angiography
Acute Ischemia
Chronic Ischemia
TREATMENT OF LOWER-EXTREMITY ATHEROSCLEROTIC DISEASES
I. Endovascular Strategies for Management of Claudication and Lower Extremity Atherosclerotic Disease
Percutaneous Transluminal Angioplasty for Claudication
Directional Atherectomy
Intravascular Stents
Thrombolysis
Subintimal Angioplasty
II. Limb Salvage and Revascularization
Surgical Intervention
Operative Options
Conduit Options
Synthetic Conduits
Allografts
Combined Revascularization and Free Tissue Transfer
Sympathectomy
III. Nonoperative Nonpharmacological Intervention
High-pressure Intermittent Compression
Gene Therapy
Intimal Hyperplasia
Angiogenesis
CHAPTER 11:
Buerger's Disease or Thromboangiitis Obliterans
INTRODUCTION
Epidemiology
Pathology
Pathogenesis
Clinical Presentation
Diagnosis
Management
Conclusion
CHAPTER 12:
Raynaud's Disease and Raynaud's Phenomenon
PATHOPHYSIOLOGY
Incidence
Clinical Features
Investigations
Management
Calcium Channel Blockers
Antithrombotic Drugs With Vasodilators
Antioxidants
Omega 3 Fatty Acids
Vitamins
Cervical and Digital Sympathectomy
Avoiding Inciting Factors
Author's Protocol
Newer Drugs
Prognosis
CHAPTER 13:
Nonspecific Aortoarteritis
CLASSIFICATION OF VASCULITIS
A. Large Vessel Vasculitis
B. Medium Sized Vessel Vasculitis
C. Small Vessel Vasculitis
INCIDENCE
EPIDEMIOLOGY
PATHOLOGY
ETIOPATHOGENESIS
CLINICAL FEATURES
DIAGNOSIS
LABORATORY FINDINGS
MANAGEMENT
A. Medical Treatment
B. Interventional Radiology
C. Surgery
PROGNOSIS
CONCLUSION
CHAPTER 14:
Arterial Aneurysms
ETIOLOGICAL CLASSIFICATION OF ARTERIAL ANEURYSMS
Clinical Presentation and Diagnosis
Management
Various Surgical Management Options Include
ABDOMINAL AORTIC ANEURYSMS (AAA)
Etiopathogenesis
Clinical Presentation
Natural History
Investigative Modalities
Management
PERIPHERAL ARTERIAL ANEURYSMS
ILLUSTRATIVE CASES
CHAPTER 15:
Arteriovenous Fistulas and Malformations
ARTERIOVENOUS FISTULA AT VARIOUS SITES
Arteriovinous Fistulas at the Base of the Neck
Carotid–Internal Jugular Vein Fistula (Fig. 15.3)
Aorta–Vena Cava Fistula
Renal Artery–Renal Vein Fistula
Aorta–Renal Vein
Portal Vein–Systemic Artery Fistula
Treatment
TRAUMATIC A-V FISTULA
Causes
Diagnosis
Investigations
Angiography
Multi-slice CT Angiography
Treatment of Traumatic AVFs
Surgical Steps
IATROGENIC A-V FISTULAS
Causes
Clinical Presentation
Management
Role of Conservative Management
Indications for Early Surgery
Endovascular Therapy
Complications in Endovascular Therapy of A-V Communication
CHAPTER 16:
Varicose Veins
ANATOMY
Perforating Veins
ETIOLOGY AND PATHOPHYSIOLOGY
RISK FACTORS
CLINICAL PRESENTATION
Physical Examination
Brodie-Trendelenburg Test
Tourniquet Tests
Perthes Maneuver
Schwartz Test
Pratt's Test
Morrissey's Cough Impulse Test
Fegan's Method for Perforators
IMAGING STUDIES
Continuous Wave Doppler Ultrasound (CWDU)
Duplex Scanning
Magnetic Resonance Venography (MRV)
Phlebography/Varicography
Classification
Widmer (1978) Classification
Porter (1988) Classification
CEAP Classification
Seven Categories Based on Objective Signs of CVD
Etiologic Classification
Anatomic Classification
Pathophysiologic Classification
Date of Classification
Level of Investigation
Treatment
Nonsurgical Treatment
Pharmacotherapy
Compression Therapy
Compression Stockings are Divided into Three Classes
Sclerotherapy
Surgical Treatment
Newer Treatments
Endovenous Laser
Radiofrequency Ablation
Ambulatory Phlebectomy
Subfascial Endoscopic Perforator Surgery
Foam Sclerotherapy
Transilluminated Powered Phlebectomy Ablation of Varicosities (TriVex)
External Valvular Stents
Endovenous Diathermy
Cryosurgery
COMPLICATIONS
CHAPTER 17:
Deep Venous Thrombosis
ANATOMY OF DEEP VENOUS SYSTEM
Deep Veins of the Calf
Deep Veins of the Thigh
Above the Thigh
EPIDEMIOLOGY
PATHOPHYSIOLOGY
RISK FACTORS
Age
Immobilization
Travel
History of Venous Thromboembolism
Malignancy
Surgery
Trauma
Pregnancy and Postpartum
Oral Contraceptives and Hormonal Therapy
Blood Group
Geography and Ethnicity
Central Venous Catheters
Inflammatory Bowel Disease
Systemic Lupus Erythematosus
Varicose Veins and Superficial Thrombophlebitis
Primary Hypercoagulable States
Antithrombin Deficiency
Protein C Deficiency
Protein S Deficiency
Factor V Leiden (APC Cofactor Defect)
Prothrombin 20210A Mutation
Hyperhomocysteinemia
Elevated Factor VIII
Fibrinolytic System Defects
Platelet Defects and Thrombosis
Wien-Penzing Defect
Sticky Platelet Syndrome
Other Risk Factors
COMPLICATIONS
Mortality
Pulmonary Embolism
The Post-thrombotic Syndrome
Calf Vein Thrombosis
DIAGNOSIS
Clinical Features
INVESTIGATIONS
Venography
Duplex Ultrasonography
Computed Tomography Venography
Magnetic Resonance Venography
Radionuclide Scanning
D-Dimer
CLINICAL PREDICTION SCORES
TREATMENT
Anticoagulant Therapy
Heparin
Low Molecular Weight Heparin (LMWH)
Oral Anticoagulants
Duration of Anticoagulation
Pregnancy
PREVENTION
Newer Anticoagulants
Thromboablative Therapy
Percutaneous Mechanical Thrombectomy
Surgical Thrombectomy
Venacaval Interruption
CHAPTER 18:
Diabetic Foot
RISK FACTORS FOR DEVELOPMENT OF DIABETIC FOOT
CLINICAL EVALUATION OF PATIENTS WITH DIABETIC FOOT
Grading of Diabetic Foot (Wagner's Classification)
Brodsky Modification (Depth - Ischemia Classification)
Depth Classification
Ischemia Classification
INVESTIGATIONS
TREATMENT OF DIABETIC FOOT
Tissue Cultured Skin Substitutes
PREVENTION
CONCLUSION
CHAPTER 19:
Hemangiomas
INTRODUCTION
Etiology
Pathogenesis
CLINICAL FEATURES
RICH
NICH
Associated Anomalies
Differential Diagnosis
Diagnosis
Treatment
COMPLICATIONS
Psychological Impact
Prognosis
CHAPTER 20:
Lumbar Sympathectomy
INTRODUCTION
ANATOMY
PHYSIOLOGY
Indications
a. Causalgia
b. Vasospasm
c. Hyperhidrosis
d. Rest Pain and Superficial Ulcerations
WORK-UP
CONTRAINDICATIONS
Operative Technique
OPEN LUMBAR SYMPATHECTOMY
Anesthesia
Position
Incision
Procedure
Postoperative Care
Laparoscopic Lumbar Sympathectomy
Retroperitoneal Lumbar Sympathectomy
Transperitoneal Lumbar Sympathectomy
Tests for Completeness
Complications
Chemical Sympathectomy
Radiofrequency Ablation
CHAPTER 21:
Amputations of Lower Extremity
INTRODUCTION
LEVELS OF AMPUTATIONS IN LOWER LIMB
Hemipelvectomy
Hip Disarticulation
Above Knee Amputation
Knee Disarticulation
Below Knee Amputation (BKA)
Syme's Amputation
Chopart Amputation
Lisfranc Amputation
Transmetatarsal Amputation
Ray Amputation
Toe Amputation
INDICATIONS FOR AMPUTATION
Numerous Indications are Present Based on Following Principles
I. Vascular Cause
II. Neoplasms
III. Infective Conditions
IV. Traumatic
V. Burns
VI. Frostbite
INVESTIGATIONS
I. Doppler Ultrasound Studies
II. Transcutaneous Oxygen Tension Measurement
III. Fluorescence Studies
IV. Xenon Studies
V. Arteriography
VI. Nutrition and Immunocompetence Studies
VII. Plethysmography
TECHNIQUE IN AMPUTATION
Hemipelvectomy
Disarticulation of Hip
Transfemoral (above knee) Amputation
Disarticulation of Knee
Transtibial (below knee) Amputation
POSTOPERATIVE CARE
Immediate Postoperative Care
Late Postoperative Care
CHAPTER 22:
Compartment Syndrome
INTRODUCTION
Historical Background
Etiology
Orthopedic Causes
Vascular Causes
Soft-tissue Causes
Iatrogenic Causes
Pathophysiology
Diagnosis
Investigations
Intracompartmental Pressure Measurement
Critical Pressure
Treatment
Surgical Decompression
Closure of Fasciotomy
CHAPTER 23:
Lymphedema
INTRODUCTION
LYMPHATIC SYSTEM
Anatomy
Lymphatic Physiology
Etiology
Pathology of Lymphedema
Classification
Primary Lymphedema
Wolfe and Kinmonth Classification
Secondary Lymphedema
CLINICAL FEATURES
Progress and Complications
Investigations
1. Routine Tests
2. Contrast Lymphography
3. Indirect Lymphangiography
4. Isotope Lymphoscintigraphy
5. MRI
6. Computed Tomography
7. Ultrasonography
MANAGEMENT
Conservative Treatment
Surgical Treatments
Physiological Procedures
Excisional Procedures
CONCLUSION
CHAPTER 24:
Portal Hypertension
INVESTIGATIONS
MANAGEMENT OF THE VARICEAL BLEEDING
Pharmacologic Therapy
Emergency Endoscopic Treatment
TIPSS (Transjugular, Intrahepatic, Portasystemic Stent Shunt)
Surgical Treatment
Emergency Portal Systemic Shunt
RISK OF FIRST BLEEDING
Primary Prophylaxis
Secondary Prophylaxis
Liver Transplantation
HYPERSPLENISM
ASCITES
HEPATIC ENCEPHALOPATHY
CHAPTER 25:
Microvascular Surgery: Basic Technique and Clinical Applications
INSTRUMENTATION
Microsurgical Instruments
Microsutures
Solutions
PREPARATION FOR MICROVASCULAR PROCEDURES
I. Setup and Operator Comfort
II. Vessel Preparation
III. Miocrovascular Anastomotic Techniques
Types
Microvascular Troubleshooting
Flap Salvage
Preventive Measures
Anesthesia and Microvascular Surgery
REPLANTATION
1. Evaluation of Replantation
FREE FLAP
Advantages of Free Flaps
Disadvantages of Free Flaps
MICROLYMPHATIC SURGERY
REVASCULARIZATION SURGERY
INDEX
TOC
Index
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