Authors: Sebouh Bazikian - PGY1 at Emory School of Medicine Integrated Vascular Surgery Program Miguel F. Manzure - vascular surgery attending the University of Southern California Keck School of Medicine involved in complex limb preservation Core Resources: Rutherford Chapters: 107, 108, 109 (Includes further information on anatomy), 112 Additional Resources: Relevant trials BEST CLI: https://pubmed.ncbi.nlm.nih.gov/36342173/ BASIL 2: https://pubmed.ncbi.nlm.nih.gov/37116524/ Relevant Audible Bleeding episodes Audible Bleeding Endovascular Basics: https://open.spotify.com/episode/7jDpkhGMauBslk8SBklCyB?si=75f0931773d24b91 Audible Bleeding eBook, CLTI Chapter: https://adam-mdmph.quarto.pub/vascular-surgery-exam-prep/clti.html Anything else useful WIFI: https://pubmed.ncbi.nlm.nih.gov/24126108/ GLASS: https://pubmed.ncbi.nlm.nih.gov/31159978/ Monophasic, Biphasic, Triphasic Waveforms: https://pubmed.ncbi.nlm.nih.gov/32667274/ Underlying disease featured in episode - peripheral arterial disease Pathophysiology/etiology narrowing of peripheral arteries caused by atherosclerotic plaques causing arterial insufficiency distal to the point of occlusion. This reduces oxygen supply to the muscles. When oxygen demand increases but cannot be met, it leads to an imbalance such as pain and poor wound healing. Risks: smoking, diabetes, hypertension, dyslipidemia, and older age Equal prevalence in men and women, peak incidence age 60-80 Coexists with CAD, DM, stroke, Afib, and renal disease Patient Presentation 20-50% asymptomatic, rest can be intermittent claudication, rest pain, or tissue loss claudication=pain or discomfort felt in the legs due to a lack of blood flow, especially during physical activity. CLTI=chronic limb threatening ischemia: rest pain lasting greater than 2 weeks or nonhealing ulcers and gangrene Physical exam: decreased skin temperature, less hair on the legs, brittle nails, atrophied muscles, shiny skin, livedo reticularis. Absent or diminished pulses Buerger sign Diagnosis Ankle brachial index: <0.9=PAD. <0.4=multilevel disease associated with tissue loss. >1.3 can mean vessel calcification Toe pressures, toe brachial indexes, and transcutaneous oxygen measurement (TcPO2) if vessels calcified Duplex ultrasound: affordable and effective, can assess both anatomy and blood flow Can also assess degree of stenosis based on ratios of systolic and diastolic velocity Angiography: gold standard. Invasive and risks of infection, hematoma, pseudoaneurysms, and contrast nephropathy. Staging: WIFI - Wound, Ischemia, and Foot Infection (see additional resources) GLASS: Global Limb Anatomy Staging System (see additional resources) Treatment (Medical/Surgical) Lifestyle modification, smoking cessation, high-intensity statins, antiplatelet therapy, and management of other medial comorbidities like HTN and DM. Structured exercise program: 3 times weekly for 12 weeks Cilostazol: phosphodiesterase III inhibitor Endovascular and surgical revascularization Endovascular offer superior perioperative outcomes but lacks durability Surgical revascularization offer durability and less reinterventions, but more invasive Indications for surgery: CLTI and lifestyle limiting claudication Relevant anatomy: Femoral triangle inguinal ligament superior, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus on the medially Contains neurovascular bundle (NAVEL) Adductor canal: bordered anteriorly by the sartorius, posteriorly by the adductor magnus and longus, and to the lateral side by the vastus medialis common femoral artery bifurcates into the profunda and the superficial femoral artery (SFA). SFA courses through adductor canal and turns into popliteal artery in the popliteal fossa GSV: originates at the ankle, tracts anterior to medial malleolus and then ascending the medial side of lower leg. Upon reaching the knee, it curves behind the medial condyles of the femur and tibia, continuing alongside the medial aspect of the thigh. Its journey culminates at the saphenofemoral junction Preoperative preparation: Identifying inflow and outflow vessels, both should be free of significant disease preop CTA or angiogram Picking a conduit Best patency=autogenous: reversed GSV most common, others are small saphenous vein, cephalic vein, etc Prosthetic: polytetrafluoroethylene (PTFE) Cryopreserved vein Surgical steps: Harvesting GSV (if GSV adequate as conduit) Dissected along its length, branches ligated, removed and reversed Can also be left insitu, so only proximal and distal aspects are mobilized, and valves are removed using valvulotome Should be at least 3mm in diameter and no significant disease (scarring, thickening) Arterial exposure Common femoral artery: lies in the medial third segment between the ASIS and the pubic symphysis. Longitudinal or oblique incision directly over the ...
