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Out of the frying pan & into the fire. Dr Duncan Anderson Vascular Surgeon www.drduncananderson.co.za. The frying pan. Traditionally the surgeon has been based in the operating theatre Preoperative angiography was routinely performed by the radiologist. Case 1: Critical limb ischaemia.

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out of the frying pan into the fire

Out of the frying pan& into the fire

Dr Duncan Anderson

Vascular Surgeon

www.drduncananderson.co.za

the frying pan
The frying pan
  • Traditionally the surgeon has been based in the operating theatre
  • Preoperative angiography was routinely performed by the radiologist
case 1 critical limb ischaemia
Case 1: Critical limb ischaemia
  • 61 year old male
  • Non-healing left ankle ulcer for 9 months
  • Risk factors: heavy smoker, hypertension & hypercholestrolaemia
  • Only left femoral pulse
  • Ankle brachial index: 0.46
case 1 critical limb ischaemia1
Case 1: Critical limb ischaemia
  • Catheter directed angiogram in the cathlab
  • Left femorodistal bypass to the posterior tibial artery
  • Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein
case 1 critical limb ischaemia2
Case 1: Critical limb ischaemia
  • Who should be referred to a vascular surgeon?
  • And which special investigations should be performed prior to referral?
who should be referred
Who should be referred?
  • Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene
  • All patients with ankle brachial index <0.9
  • Any diabetic, chronic renal failure patient or heavy smoker with absent pedal pulses
which special investigation
Which special investigation?
  • Ankle brachial index (ABI) only
    • ABI 1.3-0.9 manage vascular risk factors
    • ABI 1.3-0.9 safely apply compression bandaging for venous stasis ulceration
  • No arterial duplex doppler ultrasound
  • No CT angiography
  • No MR angiography
  • No cathlab angiography
the fire
The fire
  • Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography
  • Cathlab
  • Hybrid theatre
  • Offers a more goal directed therapy
case 2 complex varicose veins
Case 2: Complex varicose veins
  • 36 year old female
  • Recurrent bilateral varicose veins
  • Vein surgery in 2005
  • Pelvic congestion syndrome
    • Menorrhagia
    • Dyspareunia
    • Dysmenorrhoea
case 2
Case 2:
  • Suspect pelvic /ovarian vein reflux
    • Recurrent varicose veins
    • Atypical varicose veins
    • Extensive groin varicosities
    • Vulvae varicosities
    • Pelvic congestion syndrome
case 2 complex varicose veins1
Case 2: Complex varicose veins
  • CT venography
  • Not a routine special investigation (timing critical)
  • Catheter directed venography
case 2 complex varicose veins2
Case 2: Complex varicose veins
  • Traditionally vein ligation & stripping
  • Endovenous laser or radiofrequency (VNUS) ablation
    • No groin wound
    • No thigh bruising
    • Less postoperative pain
    • Earlier mobilization
vnus ablation
VNUS ablation
  • Radiofrequency ablation
  • Cathlab or rooms
  • Ultrasound-guided
  • Tumescence infiltration
  • Immediate ambulation
vnus ablation1
VNUS ablation
  • Tumescence infiltration
    • Local anaesthesia
    • Facilitates ablation by vein compression
    • Reduces risk of deep vein thrombosis
    • Creates “heat sink” to protect surrounding tissue
vnus ablation2
VNUS ablation
  • Less pain & less bruising than laser ablation
  • Who should be referred to a vascular surgeon?
who should be referred1
Who should be referred?
  • Atypical distribution of varicose veins
  • Recurrent varicose vein
  • Associated chronic venous insufficiency (venous stasis dermatitis or venous ulcer)
  • Suspicion of pelvic/ovarian vein reflux
  • VNUS ablation for better cosmetic result, less pain & immediate mobilization
case 3 false aneurysm
Case 3: False aneurysm
  • 49 year old female
  • Painful swelling right groin 2 weeks after cathlab
  • BMI 40.4
  • Large false aneurysm flush with common femoral artery (no neck)
case 3 false aneurysm1
Case 3: False aneurysm
  • Direct surgical approach
  • Burst on skin incision
  • Direct digital control of 2cm defect in common femoral artery
  • Total of 4 unit blood transfusion
case 3 false aneurysm2
Case 3: False aneurysm
  • Proximal control digitally through pelvis
  • Repaired with vein patch
  • Discharged after 6 days
  • High risk of wound & graft sepsis
case 3 false aneurysm3
Case 3: False aneurysm
  • Negative surgical aspects
    • Additional open surgical procedure
    • Risk of anaesthesia
    • Prolonged hospital stay
    • Postoperative pain
    • High risk of wound & graft sepsis
    • Difficult mobilization
case 4 false aneurysm
Case 4: False aneurysm
  • 74 year old female
  • Painful right groin swelling 1 day after cathlab
  • BMI 32.2
  • Dropped haemoglobin from 13g% to 9g%
case 4 false aneurysm1
Case 4: False aneurysm
  • Long & narrow neck
  • Ultrasound-guided thrombin injection
case 4 false aneurysm3
Case 4: False aneurysm
  • Angioplasty balloon to arrest flow within aneurysm
  • Thrombin (factor IIa) converts fibrinogen to fibrin
  • Discharged within 48hrs
if all that you have is a hammer then all that you ll see are nails
“If all that you have is a hammer,then all that you’ll see are nails”

VASCULAR SURGEON

UROLOGIST

ANAESTHETIST

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