PERIPHERAL VASCULAR DISEASE

492 Section II / General Surgery

How can you remember the orientation of the lower exterior arteries below the knee on A-gram?

What is peripheral vascular disease (PVD)?

What is the most common site of arterial

atherosclerotic occlusion in the lower extremities?

Use the acronym “LAMP”:

Lateral Anterior tibial

Medial Posterior tibial

Occlusive atherosclerotic disease in the lower extremities

Occlusion of the SFA in Hunter’s canal

What classically resolves rest pain?

How can vascular causes of claudication be differentiated from nonvascular causes, such as neurogenic claudication or arthritis?

What is the differential diagnosis of lower extremity claudication?

Hanging the foot over the side of the bed or standing; gravity affords some extra flow to the ischemic areas

History (in the vast majority of patients) and noninvasive tests; remember, vascular claudication appears after a specific distance and resolves after a specific time of rest while standing (not so with most other forms of claudication)

Neurogenic (e.g., nerve entrapment/ discs), arthritis, coarctation of the aorta, popliteal artery syndrome, chronic compartment syndrome, neuromas, anemia, diabetic neuropathy pain

What are the signs of PVD?

What is the site of a PVD ulcer vs. a venous stasis ulcer?

What is the ABI?

What ABIs are associated with normals, claudicators, and rest pain?

Who gets false ABI readings?

What are PVRs?

Prior to surgery for chronic PVD, what diagnostic test will every patient receive?

What is the bedside management of a patient with PVD?

Chapter 66 / Vascular Surgery 493

Absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis/ulcers/infection

PVD arterial insufficiency ulcer—usually on the toes/foot

Venous stasis ulcer—medial malleolus (ankle)

Ankle to Brachial Index (ABI); simply, the ratio of the systolic blood

pressure at the ankle to the systolic blood pressure at the arm (brachial artery) A:B; ankle pressure taken with Doppler; the ABI is noninvasive

Normal ABI— 1.0

Claudicator ABI— 0.6

Rest pain ABI— 0.4

Patients with calcified arteries, especially those with diabetes

Pulse Volume Recordings; pulse wave forms are recorded from lower extremities representing volume of blood per heart beat at sequential sites down leg

Large wave form means good collateral blood flow

(Noninvasive using pressure cuffs)

A-gram (arteriogram: dye in vessel and x-rays) maps disease and allows for best treatment option (i.e., angioplasty vs. surgical bypass vs. endarterectomy)

Gold standard for diagnosing PVD

1.Sheep skin (easy on the heels)

2.Foot cradle (keeps sheets/blankets off the feet)

3.Skin lotion to avoid further cracks in the skin that can go on to form a fissure and then an ulcer

What is the treatment of claudication?

For the vast majority, conservative treatment, including exercise, smoking cessation, treatment of HTN, diet, aspirin, with or without Trental (pentoxifylline)

How does aspirin work?

How does Trental® (pentoxifylline) work?

What is the risk of limb loss with claudication?

What is the risk of limb loss with rest pain?

In the patient with PVD, what is the main postoperative concern?

Inhibits platelets (inhibits cyclooxygenase and platelet aggregation)

Results in increased RBC deformity and flexibility (Think: pentoXifylline RBC fleXibility)

5% limb loss at 5 years (Think: 5 in 5), 10% at 10 years (Think: 10 in 10)

50% of patients will have amputation of the limb at some point

Cardiac status, because most patients with PVD have coronary artery disease; 20% have an AAA

MI is the most common cause of postoperative death after a PVD operation

What graft material has the longest patency rate?

What is an “in situ” vein graft?

Autologous vein graft

Saphenous vein is more or less left in place, all branches are ligated, and the vein valves are broken with a small hook or cut out; a vein can also be used if reversed so that the valves do not cause a problem

What type of graft is used for above-the-knee FEM-POP bypass?

What type of graft is used for below-the-knee FEM-POP or FEM-DISTAL bypass?

What is DRY gangrene?

Either vein or Gortex® graft; vein still has better patency

Must use vein graft; prosthetic grafts have a prohibitive thrombosis rate

Dry necrosis of tissue without signs of infection (“mummified tissue”)