Out of the frying pan into the fire
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Out of the frying pan & into the fire PowerPoint PPT Presentation


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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

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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 aneurysm2

Case 4: False aneurysm


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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