HAIMOVICI’S VASCULAR SURGERY

To my son Michael Sam and my daughter Andrea Rachel for being the major source of inspiration and happiness.

Enrico Ascher, July 2012

Haimovici’s Vascular Surgery

EDITOR-IN-CHIEF

ENRICO ASCHERChief of Vascular and Endovascular SurgeryLutheran Medical Center;Professor of SurgeryMount Sinai School of MedicineNew York, NY, USA

CO-EDITORS

FRANK J . VEITHPETER GLOVICZKI

ASSOCIATE EDITORS

KEITH D. CALLIGARO R. CLEMENT DARLING III K. CRAIG KENTPETER F. LAWRENCE GREGORY MONETAJOHN J. RICOTTA

6TH EDITION

A John Wiley & Sons, Ltd., Publication

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Library of Congress Cataloging-in-Publication Data

Haimovici’s vascular surgery. – 6th ed. / editor-in-chief, Enrico Ascher ; co-editors, Frank J. Veith, Peter Gloviczki ; associate editors, Keith D. Calligaro ... [et al.]. p. ; cm. Vascular surgery Includes bibliographical references and index. ISBN 978-1-4443-3071-7 (hardcover : alk. paper) I. Haimovici, Henry, 1907-2001. II. Ascher, Enrico. III. Title: Vascular surgery. [DNLM: 1. Vascular Surgical Procedures. 2. Vascular Diseases–diagnosis. 3. Vascular Diseases–surgery. WG 170]

617.4'13–dc23 2011048151

A catalogue record for this book is available from the British Library.

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Cover image: Courtesy of Eraxion/iStockphotoCover design by Steve Thompson

Set in 9.5/12 pt Palatino by Toppan Best-set Premedia Limited

1 2012

Contents

Preface, x

Preface to the Fifth Edition, xi

Contributors, xii

List of Abbreviations, xx

PART I VASCULAR IMAGING TECHNIQUES AND PHYSIOLOGIC TESTING

1 Arterial and Venous Duplex Scanning, 3Gregory L. Moneta

2 Duplex Arteriography for Lower Extremity Revascularization, 28Enrico Ascher, Anil Hingorani, and Natalie Marks

3 Fundamentals of Angiography, 44Douglas B. Hood and Kim J. Hodgson

4 Arteriographic Patterns of Atherosclerotic Occlusive Disease of the Lower Extremity, 56Henry Haimovici

5 Computed Tomography in Vascular Disease, 79Aoife N. Keeling, Peter A. Naughton, Frederick L. Hoff, and William H. Pearce

6 Magnetic Resonance Angiography, 99April Farley, Javier E. Anaya-Ayala, Mark G. Davies, and Alan B. Lumsden

7 Intravascular Ultrasound Imaging, 112George Kopchok and Rodney A. White

PART II BASIC SCIENCE IN VASCULAR DISEASES

8 Hemodynamics of Vascular Disease: Applications to Diagnosis and Treatment, 127David S. Sumner

9 Atherosclerosis: Biological and Surgical Considerations, 148Bauer E. Sumpio

10 Neointimal Hyperplasia: Basic Considerations, 178Lynn S. Model and Alan Dardik

11 Therapeutic Angiogenesis, 197Bo Liu and K. Craig Kent

12 Thrombogenesis and Thrombolysis, 209Takki A. Momin, Robyn A. Macsata, and Anton N. Sidawy

13 Etiology of Abdominal Aortic Aneurysms, 221Sartaj S. Sanghera, Anil Hingorani, and Martin D. Tilson

14 An Evidence-based Approach to Cardiopulmonary Risk Assessment for Vascular Surgery Procedures, 233Joel H. Horovitz

PART III BASIC OPEN VASCULAR TECHNIQUES

15 Vascular Sutures and Anastomoses, 243Henry Haimovici

16 Patch-graft Angioplasty, 253Henry Haimovici

v

vi Contents

17 Endarterectomy, 259Henry Haimovici

18 Balloon Angioplasty of Peripheral Arteries and Veins, 268Douglas B. Hood and Kim J. Hodgson

19 Stents for Peripheral Arteries and Veins, 280Samuel S. Ahn, Carber C. Huang, and Foster A. Hays

20 Thrombolytic Therapy for Peripheral Arterial and Venous Thrombosis, 301Michael B. Silva Jr, Charlie C. Cheng, and Lorraine Choi

PART IV OPEN SURGICAL EXPOSURE OF ARTERIES

21 Exposure of the Carotid Artery, 317Henry Haimovici

22 The Vertebrobasilar System: Anatomy and Surgical Exposure, 320Enrique Criado and Ramon Berguer

23 Trans-sternal Exposure of the Great Vessels of the Aortic Arch, 324Calvin B. Ernst

24 Extrathoracic Surgical Exposure for Distal Revascularization of Brachiocephalic Branches, 331Henry Haimovici

25 Open Surgical Exposure of Upper Extremity Arteries, 338Henry Haimovici

26 Transperitoneal Exposure of Abdominal Aorta and Iliac Arteries, 351Henry Haimovici

27 Retroperitoneal Exposure of Abdominal Aorta, 360Calvin B. Ernst

28 Retroperitoneal Exposure of Iliac Arteries, 366Henry Haimovici

29 Open Surgical Exposures of Arteries in the Lower Extremity, 372Henry Haimovici

PART V CEREBROVASCULAR INSUFFICIENCY

30 Medical Management of Carotid Artery Disease, 391Russell H. Samson

31 Carotid Endarterectomy: Indications, Techniques, and Results, 405Bruce A. Perler

32 Eversion Carotid Endarterectomy, 419Jorge Rey, Sean P. Roddy, and R. Clement Darling III

33 Carotid Stenting: Indications, Techniques, and Results, 427Tejas R. Shah and Peter L. Faries

34 Cerebral Protection Devices During Carotid Stenting, 437Amit R. Shah and Evan C. Lipsitz

35 Vertebrobasilar Disease: Surgical Management, 448Enrique Criado and Ramon Berguer

36 Nonatherosclerotic Cerebrovascular Disease, 456Gary R. Seabrook

PART VI AORTIC AND ILIAC ANEURYSMS

37 Indications, Techniques and Results of Open Repair of Ascending and Transverse Aortic Arch Aneurysms, 475Hazim J. Safi, Anthony L. Estrera, Roy Sheinbaum, and Charles C. Miller III

38 Hybrid Repair of Aortic Arch Aneurysms, 486Gustavo S. Oderich and Adam H. Power

39 Endovascular Management of Thoracic Aortic Aneurysms and Dissections, 504Donald T. Baril and Michel S. Makaroun

40 Open Repair of Thoracoabdominal Aortic Aneurysms, 517Joseph Huh, Scott A. LeMaire, and Joseph S. Coselli

41 Open Repair of Abdominal Aortic Aneurysms, 533Colin M. Brady and Elliot L. Chaikof

Contents vii

42 Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms, 554Jeffrey Hnath, Manish Mehta, Yaron Sternbach, John B. Taggert, and R. Clement Darling III

43 Fenestrated and Branched Stent Grafts for the Treatment of Complex Aortic Aneurysms, 565Joseph J. Ricotta II

44 Endovascular Treatment of Ruptured Infrarenal Aortic and Iliac Aneurysms, 582Frank J. Veith and Neal S. Cayne

45 Open Surgical Treatment of Isolated Iliac Aneurysms, 590Henry Haimovici

46 Endovascular Grafts in the Treatment of Isolated Iliac Aneurysms, 594Todd L. Berland, Frank J. Veith, Karan Garg, and Neal S. Cayne

47 Infected Aortic Grafts: General Considerations and Techniques, 602Taylor A. Smith and G. Patrick Clagett

48 Para-anastomotic Aortic Aneurysms: General Considerations and Techniques, 612John J. Ricotta

PART VII VISCERAL VESSELS

49 Surgery of the Celiac Artery for Occlusive Disease and Arcuate Ligament Syndrome, 627Juan Carlos Jimenez and William J. Quinones-Baldrich

50 Management of Acute and Chronic Mesenteric Ischemia, 639Natalia O. Glebova and Julie A. Freischlag

51 Endovascular Treatment of Mesenteric Occlusive Disease, 653Carlos F. Bechara and Peter H. Lin

52 Renal Artery Revascularization, 664Keith D. Calligaro and Matthew J. Dougherty

53 Renal Artery Fibrodysplasia and Renovascular Hypertension, 680James C. Stanley and Jonathan L. Eliason

54 Visceral Artery Aneurysms, 690Matthew J. Dougherty and Keith D. Calligaro

PART VIII LOWER EXTREMITY OCCLUSIVE AND NON-OCCLUSIVE ARTERIAL DISEASE

55 Acute Arterial Occlusion of the Lower Extremities, 703Kenneth Ouriel

56 Aortoiliac Occlusive Disease, 710David C. Brewster

57 Endovascular Treatment of Aortoiliac Artery Stenosis and Occlusions, 736Jeanwan Kang and Christopher J. Kwolek

58 Infrainguinal Arterial Disease, 749John Byrne, R. Clement Darling III, and Frank J. Veith

59 Bypasses to Plantar Arteries and Other Branches of Tibial Arteries, 761Enrico Ascher and Frank J. Veith

60 Role of Surgical Options for Critical Lower Limb Ischemia, 767Frank J. Veith, Neal S. Cayne, Nicholas J. Gargiulo III, Evan C. Lipsitz, and Enrico Ascher

61 Adjuvant Surgical Techniques for Limb Salvage, 776Robyn A. Macsata and Anton N. Sidawy

62 Endovascular Treatment of Infrapopliteal Arteries, 786Peter A. Schneider, W. Austin Blevins, and Nicolas Nelken

63 Popliteal Artery Aneurysms, 801Javairiah Fatima and Peter Gloviczki

64 Endovascular Treatment of Popliteal Artery Aneurysms: The Role of Stent-Grafts and Thrombolysis, 811Alik Farber and Tze-Woei Tan

65 Duplex-guided Balloon Angioplasty for Infrainguinal Arterial Occlusive and Aneurysmal Disease, 821Enrico Ascher, Natalie Marks, and Anil Hingorani

viii Contents

66 Extra-anatomic Bypasses, 832Enrico Ascher, Frank J. Veith, and Kapil Gopal

67 Infected Extracavitary Prosthetic Grafts, 845Keith D. Calligaro and Matthew J. Dougherty

68 Popliteal Entrapment and Chronic Compartment Syndrome: Unusual Causes for Claudication in Young Adults, 852William D. Turnipseed

69 Lumbar Sympathectomy: Current Indications and Techniques, 860Ali F. AbuRahma

70 Nonatherosclerotic Diseases of Small Arteries, 873Henry Haimovici and Yoshio Mishima

71 Intraoperative Assessment and Postoperative Surveillance of Vascular Reconstructions, 898Gustavo De Jesús-Gómez and Dennis F. Bandyk

PART IX VASCULAR TRAUMA

72 Vascular Trauma, 909Ramyar Gilani, Asher Hirshberg, and Kenneth L. Mattox

73 Ankle and Foot Fasciotomy for Compartment Syndrome of the Foot, 928Enrico Ascher

74 Post-Traumatic Pain Syndrome: Complex Regional Pain Syndrome, 932Ali F. AbuRahma and Albeir Y. Mousa

PART X UPPER EXTREMITY VASCULAR DISEASE

75 Vasospastic Disease of the Upper Extremity: Primary Raynaud’s Syndrome, 949Gregory L. Moneta and Gregory J. Landry

76 Arterial Surgery of the Upper Extremity, 962Rodeen Rahbar, Richard F. Neville, and Anton N. Sidawy

77 Neurogenic Thoracic Outlet Syndrome and Pectoralis Minor Syndrome, 981Richard J. Sanders

78 Venous Thoracic Outlet Syndrome, 997Peter F. Lawrence, Hugh Gelabert, Brian G. DeRubertis, and David A. Rigberg

79 Arterial Thoracic Outlet Syndrome, 1004Frank J. Veith and Juan Carlos Jimenez

80 Upper Thoracic Sympathectomy: Conventional Technique, 1015Henry Haimovici

81 Thoracoscopic Sympathectomy, 1023Igor Brichkov and Jason P. Shaw

PART XI ARTERIAL-VENOUS MALFORMATION, ACCESS FOR HEMODIALYSIS AND PORTAL HYPERTENSION

82 Arteriovenous Fistulas and Vascular Malformations, 1035Peter Gloviczki, Audra A. Noel, and Larry H. Hollier

83 Vascular Access for Dialysis, 1060Andres Schanzer and Harry Schanzer

84 Portal Hypertension, 1078Ian C. Carmody and John C. Bowen

85 Endovascular Treatment of Portal Hypertension, 1095Yosef Golowa and Jacob Cynamon

PART XII VENOUS AND LYMPHATIC DISORDERS

86 Clinical Application of Objective Testing in Venous Insufficiency, 1109John J. Bergan and Warner P. Bundens

87 Varicose Veins, 1121Jose I. Almeida and Jeffrey K. Raines

88 Superficial Thrombophlebitis, 1131Anil Hingorani and Enrico Ascher

Contents ix

89 Acute Deep Vein Thrombosis and Contemporary Venous Thrombectomy, 1136Anthony J. Comerota

90 Acute Upper Extremity Deep Venous Thrombosis, 1154Anil Hingorani and Enrico Ascher

91 Vena Cava Filters, 1160Linda M. Harris and Raphael Blochle

92 Repair of Iliac and Iliocaval Venous Obstructions, 1173Seshadri Raju and Peter Neglen

93 Ablation of Major Incompetent Superficial Veins, 1185Manju Kalra and Peter Gloviczki

94 Management of Perforator-vein Incompetence, 1201Javier E. Anaya-Ayala, Mark G. Davies, Eric K. Peden, and Alan B. Lumsden

95 Ischemic Venous Thrombosis: Phlegmasia Cerulea Dolens and Venous Gangrene, 1213Jesse M. Manunga Jr and Peter Gloviczki

96 Diagnosis and Management of Lymphedema, 1221Harry Ma and Mark Iafrati

PART XIII AMPUTATIONS AND REHABILITATION

97 Amputation of the Lower Extremity: General Considerations, 1239Henry Haimovici

98 Major Amputations, 1243Alexander Shiferson and Henry Haimovici

99 Postoperative and Preprosthetic Management for Lower Extremity Amputations, 1260Yeongchi Wu

100 Prosthetic Fitting and Management of Lower Extremity Amputees, 1268Jan J. Stokosa

Index, 1287

Preface

The editor and publishers have made every effort to contact all the copyright holders to obtain their permis-sion to reproduce copyright material. However, if any have been inadvertently overlooked, the publisher will

x

be pleased to make the necessary arrangements at the first opportunity.

Henry Haimovici was one of the founding fathers of vascular surgery and it has been a privilege and an honor for me to be allowed to help edit yet another version of his book. Henry died on July 10, 2001 at the age of 93 in New York City following a brilliant clinical and academic career as a vascular surgeon. Henry was a prolific scientific researcher and a well respected surgeon-scientist who contributed in many ways for the maturation of vascular surgery. His pioneer work in the understanding of the pathophysiol-ogy and treatment of vascular diseases is impressive. One example is the recognition of renal and metabolic complications of extensive venous thrombosis of the lower extremities leading to gangrene. Henry called it “ischemic venous thrombosis” but the condition became popular under the name of phlegmasia cerula dolens. Dr. Haimovici’s leadership position among vascular surgeons worldwide led him to be one of the founders of the International Society for Cardiovascular Surgery as well as a founding co-editor of the Journal of Cardio-vascular Surgery. He became president of the presti-gious North American Chapter of the ISCVS (1959–1960) and in 1986 he was elected a corresponding member of the French National Academy of Medicine, an honor bestowed upon so few of the great academicians. Henry Haimovici, a mentor and friend, continues to live among us through his many important contributions to vascu-lar surgery.

Since the last edition of Haimovici’s Vascular Surgery in 2004, endovascular surgery and management of venous diseases continued to play an increasingly important role in the daily activities of vascular sur-

geons. Accordingly, I was elated when both Drs. Frank J. Veith and Peter Gloviczki accepted to be the principal Co-Editors of the current edition. These legendary sur-geons have added significantly to the book and I want to thank them for all their contributions. Equally, I need to recognize and thank all the Co-Editors who did an excellent job reviewing the various chapters and for writing their own chapters. Without this superb group of highly talented surgeons the 6th edition would not have come to fruition.

This edition follows the same principles originally outlined by Henry Haimovici, that is, a combination of fundamental surgical principles with well established vascular and endovascular techniques. Of the 100 chap-ters in this edition, 31 are totally new chapters and most others have been updated. We left most of Haimovici’s chapters unchanged since they are technical in nature and very well described. I believe the readers of this book will find these and all other chapters to be of great value.

I want to thank Dr. Anil P. Hingorani for his contri-butions to the book and for allowing me the time to complete this and many other projects. Anne Ober, my assistant of 16 years has been very helpful in follow-ing-up with the various authors and keeping us on schedule. Lastly, I want to thank Wiley-Blackwell for all their support and guidance during the creation of this edition.

Enrico Ascher, MDNew York, New York

2012

Enrico Ascher

Preface to the Fifth Edition

It has been nearly three decades since the late Dr Henry Haimovici (1907–2001) first presented to us his land-mark publication Vascular Surgery: Principles and Tech-niques. Even then he observed that, in this historically brief period of time, we had already experienced momentous developments in the magnitude and scope of our specialty. I believe that, unlike any other period of time and unlike any other surgical specialty, we have also maintained the ability to focus and redirect our craft in tandem with, if not in advance of, the changing needs of our patients and the technological advance-ments available to us. As a great pioneer of vascular surgery, Dr Haimovici was a principal instrument of our success throughout the infancy and maturation of vas-cular surgery. He was ever committed to its future beyond measure. Henry was also my mentor and a great friend. I am forever indebted to him for the privilege of assuming editorship of this grand textbook.

We are also saddened by the loss of yet another great leader in vascular surgery: D. Eugene Strandness, Jr., MD (1928–2002). Dr Strandness fielded numerous contributions throughout the formative years of nonin-vasive vascular testing and ultimately established what has now become our most effective asset in the diagno-sis of vascular disease—the vascular laboratory. His early work focused on physiologic tests, but he was also responsible for the development and application of direct ultrasonic methods for vascular diagnosis. Working with engineers at the University of Washing-ton, he combined a B-mode imaging system and a Doppler flow detector to create the first duplex scanner.

xi

These explorers of science were prolific in their contri-butions to our specialty through their research, publica-tions, and societal leaderships. It is in their footsteps that the current and successive generations of vascular leaders must walk—and they have left great shoes for them to fill.

We are proud to have returning Section Editors Larry Hollier (Aortic and Peripheral Aneurysms), Eugene Strandness (Imaging Techniques), and Jonathan B. Towne (Acute Arterial Occlusions of the Lower Extremities). We are also fortunate to have joining us K. Craig Kent (Basic Cardiovascular Problems), John J. Ricotta (Cere-brovascular Insufficiency), Keith D. Calligaro (Visceral Vessels), Gregory L. Moneta (Specific Upper Extremity Occlusions), and William H. Pearce (Venous and Lym-phatic Surgery) as Section Editors.

This 5th edition of Haimovici’s Vascular Surgery remains true to its heritage of the comprehensive inspec-tion of the practice of vascular surgery. Innovations in operative technique and reflections on noninvasive diagnostic imaging have been examined and each topic has been updated and expanded. This textbook has now included the most current topics regarding endovascu-lar therapy. Extensive changes have been made to this edition—fully 75 chapters have been revised and 25 new chapters have been added.

Enrico Ascher, MDNew York, New York

2003

Contributors

Ali F. AbuRahma MDProfessor of SurgeryChief, Vascular and Endovascular SurgeryDirector, Vascular Surgery FellowshipMedical Director, Vascular LaboratoryCo-Director, Vascular Center of ExcellenceRobert C. Byrd Health Sciences CenterWest Virginia UniversityCharleston, WV, USA

Samuel S. Ahn MD, FACSClinical Professor of SurgeryUCLA School of Medicine;Attending SurgeonUCLA Center for the Health SciencesDivision of Vascular SurgeryLos Angeles, CA, USA

Jose I. Almeida MD, FACS, RVTDirector, Miami Vein CenterVoluntary Associate Professor of SurgeryUniversity of Miami—Jackson Memorial HospitalMiami Vein CenterMiami, FL, USA

Enrico Ascher MDChief of Vascular and Endovascular Surgery Lutheran Medical Center;Professor of SurgeryMount Sinai School of MedicineNew York, NY, USA

Javier E. Anaya-Ayala MDResearch Vascular FellowDepartment of Cardiovascular SurgeryMethodist DeBakey Heart and Vascular CenterHouston, TX, USA

Dennis F. Bandyk MDProfessor of SurgeryDivision of Vascular and Endovascular SurgeryUniversity of California San DiegoLa Jolla, CA, USA

Donald T. Baril MDDivision of Vascular SurgeryUniversity of Pittsburgh Medical CenterPittsburgh, PA, USA

xii

Carlos F. Bechara MD, MSAssistant Professor of SurgeryBaylor College of MedicineHouston, TX, USA

John J. Bergan MD, FACSProfessor of SurgeryUniversity of California, San DiegoProfessor of SurgeryUniformed Services of the Health SciencesBethesda, MD, USA

Ramon Berguer MD, PhDProfessor of SurgeryUniversity of MichiganSchool of MedicineAnn Arbor, MI, USA

Todd L. Berland MD, RPVIAssistant Professors of SurgeryNew York University Medical CenterNew York, NY, USA

W. Austin Blevins MDDivision of Vascular TherapyHawaii Permanente Medical GroupKaiser Foundation HospitalHonolulu, HI, USA

Raphael Blochle MDAssistant Professor of SurgeryThe State University of New YorkBuffalo, NY, USA

John C. Bowen MDChairman Emeritus, Department of SurgeryOchsner Clinic FoundationNew Orleans, LA, USA

Colin M. Brady MDDivision of Vascular Surgery and Endovascular TherapyEmory University School of MedicineAtlanta, GA, USA

David C. Brewster MDClinical Professor of SurgeryHarvard Medical School;SurgeonMassachusetts General HospitalBoston, MA, USA

Contributors    xiii

Igor Brichkov MDAttending SurgeonDivision of Thoracic SurgeryMaimonides Medical CenterBrooklyn, NY, USA

Warner P. Bundens MDAssistant Clinical Professor of SurgeryUniversity of CaliforniaSan Diego, CA, USA

John Byrne MDClinical Fellow in Vascular SurgeryAlbany Medical CenterAlbany, NY, USA

Keith D. Calligaro MDAssociate Clinical ProfessorUniversity of Pennsylvania School of Medicine;Chief, Section of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

Neal S. Cayne MD, FACSAssistant Professor of SurgeryNew York University Medical CenterNew York, NY, USA

Elliot L. Chaikof MD, PhDJohnson and Johnson Professor of SurgeryHarvard Medical School;Chairman, Roberta and Stephen R. Weiner Department of Surgery;Surgeon-in-Chief Beth Israel Deaconess Medical CenterBoston, MA, USA

Charlie C. Cheng MDAssistant Professor of SurgeryDivision of Vascular Surgery and Endovascular TherapyTexas Vascular CenterThe University of Texas Medical BranchGalveston, TX, USA

Lorraine Choi MDAssistant Professor of SurgeryDivision of Vascular Surgery and Endovascular TherapyTexas Vascular CenterThe University of Texas Medical BranchGalveston, TX, USA

G. Patrick Clagett MDChairman, Division of Vascular and Endovascular MedicineSurgeryUniversity of Texas Southwestern Medical CenterDallas, TX, USA

Anthony J. Comerota MD, FACS, FACCAdjunct Professor of SurgeryUniversity of MichiganDirector, Jobst Vascular InstituteThe Toledo HospitalToledo, OH, USA

Joseph S. Coselli MDProfessor and Chief of the Division of Cardiothoracic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of Medicine;Chief of the Section of Adult Cardiac SurgeryThe Texas Heart Institute at St. Luke’s Episcopal HospitalHouston, TX, USA

Enrique Criado MDProfessor of SurgeryUniversity of Michigan School of MedicineAnn Arbor, MI, USA

Jacob Cynamon MDClinical Professor of RadiologyAlbert Einstein College of Medicine;Director, Division of Vascular and Interventional RadiologyMontefiore Medical CenterBronx, NY, USA

Alan Dardik MD, PhDAssociate Professor of SurgeryDepartment of SurgeryThe Yale University School of MedicineNew Haven, CT, USA

R. Clement Darling III MDProfessor of SurgeryAlbany Medical College;Chief, Division of Vascular SurgeryAlbany Medical CenterAlbany, NY, USA

Mark G. Davies MD, PhD, MBAProfessor of SurgeryWeill Medical College at Cornell UniversityNew York, NY;Department of Cardiovascular SurgeryMethodist DeBakey Heart and Vascular CenterHouston, TX, USA

Brian G. DeRubertis MDAssistant Professor of Surgery David Geffen School of Medicine at UCLALos Angeles, CA, USA

Matthew J. Dougherty MD, FACSAssistant Clinical ProfessorUniversity of PennsylvaniaSection of Vascular SurgeryPennsylvania HospitalPhiladelphia, PA, USA

xiv    Contributors

Jonathan L. Eliason MDAssistant Professor of SurgerySection of Vascular SurgeryUniversity of MichiganAnn Arbor, MI, USA

Calvin B. Ernst MDClinical Professor of SurgeryUniversity of Michigan Medical School;Head, Division of Vascular SurgeryHenry Ford HospitalDetroit, MI, USA

Anthony L. Estrera MDChief of Cardiac SurgeryDepartment of Cardiothoracic and Vascular SurgeryThe University of Texas at Houston Medical SchoolMemorial Hermann Heart and Vascular InstituteHouston, TX, USA

Alik Farber MDChief of Vascular and Endovascular SurgeryBoston Medical Center;Associate Professor of Surgery and RadiologyBoston University School of MedicineBoston, MA, USA

April Farley BSBaylor College of MedicineHouston, TX, USA

Peter L. Faries MD, FACSDivision Chief, Vascular SurgeryProfessor of SurgeryProfessor of RadiologyMount Sinai Medical CenterNew York, NY, USA

Javairiah Fatima MB, BSResident, Department of SurgeryMayo ClinicRochester, MN, USA

Julie A. Freischlag MDThe William Stewart Halsted Professor of SurgeryChair, Department of SurgerySurgeon-in-Chief, Department of SurgeryJohns Hopkins Medical InstitutionsBaltimore, MD, USA

Karan Garg MDSurgery ResidentNew York University Medical CenterNew York, NY, USA

Nicholas J. Gargiulo III MDUniversity of RochesterRochester, NY, USA

Ramyar Gilani MDMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

Natalia O. Glebova MD, PhDResident in General SurgeryJohns Hopkins HospitalBaltimore, MD, USA

Peter Gloviczki MDProfessor of SurgeryMayo Medical School;Chair, Division of Vascular SurgeryDirector, Gonda Vascular CenterMayo Clinic and FoundationRochester, MN, USA

Yosef Golowa MDClinical Assistant Professor of RadiologyAlbert Einstein College of Medicine;Attending Radiologist, Division of Vascular and Interventional RadiologyMontefiore Medical CenterBronx, NY, USA

Kapil Gopal MD, MBAAssistant Professor of SurgeryUniversity of Maryland School of MedicineBaltimore, MD, USA

Henry Haimovici MD (deceased)Former Foreign Corresponding MemberFrench National Academy of MedicineParis, FranceFormer Clinical Professor Emeritus of SurgeryAlbert Einstein College of Medicine at Yeshiva UniversityFormer Senior Consultant andChief Emeritus of Vascular SurgeryMontefiore Medical CenterBrooklyn NY, USA

Linda M. Harris MD, FACSAssociate Professor of SurgeryThe State University of New YorkBuffalo, NY, USA

Foster A. Hays BSUniversity of Texas Southwestern Medical CenterDallas, TX, USA

Asher Hirshberg MDProfessor of SurgeryState University of New YorkDownstate College of Medicine;Director of Vascular SurgeryKings County Hospital CenterBrooklyn, NY, USA

Contributors    xv

Anil Hingorani MDAttending SurgeonLutheran Medical Center;Associate ChairmanThe Vascular Institute of New York;Associate Professor of SurgeryMount Sinai School of MedicineNew York, NY, USA

Jeffrey Hnath MDAlbany Medical College / Albany Medical Center HospitalThe Institute for Vascular Health and DiseaseAlbany, NY, USA

Kim J. Hodgson MDProfessor and ChairDivision of Vascular SurgerySouthern Illinois UniversitySchool of MedicineSpringfield, IL, USA

Frederick L. Hoff MDAssistant Professor of RadiologyDepartment of RadiologyNorthwestern University Medical SchoolChicago, IL, USA

Douglas B. Hood MDAssociate ProfessorDivision of Vascular SurgerySouthern Illinois UniversitySchool of MedicineSpringfield, IL, USA

Joel H. Horovitz MD, FACS, FRCS(C)Vice Chairman, Department of SurgeryDirector, General SurgeryMaimonides Medical CenterBrooklyn, NY, USA

Larry H. Hollier MD, FACS, FACC, FRCS (Eng)Chancellor of Louisiana State UniversityHealth Sciences CenterNew Orleans, LA, USA

Carber C. Huang MDEndovascular Fellow, Division of Vascular SurgeryUCLA School of MedicineLos Angeles, CA, USA

Joseph Huh MDAssociate Professor, Division of Cardiothoracic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of Medicineand Cardiovascular Surgery StaffThe Texas Heart Institute at St. Luke’s Episcopal HospitalHouston, TX, USA

Mark Iafrati MDChief, Vascular SurgeryDirector Vascular Medicine CenterTufts Medical CenterBoston, MA, USA

Juan Carlos Jimenez MD, FACSAssistant Professor of SurgeryGonda (Goldschmied) Vascular CenterDavid Geffen School of Medicine at UCLA;Attending SurgeonRonald Reagan UCLA Medical CenterUCLA-Olive View Medical CenterUCLA-Santa Monica HospitalLos Angeles, CA, USA

Gustavo De Jesús-Gómez MDDivision of Vascular and Endovascular Surgery,University of South Florida College of MedicineTampa, FL, USA

Jeanwan Kang MDVascular Surgery FellowMassachusetts General HospitalDivision of Vascular and Endovascular SurgeryBoston, MA, USA

Manju Kalra MBBSAssociate Professor of Surgeryand Consultant, Division of Vascular and Endovascular SurgeryMayo ClinicRochester, MN, USA

Aoife N. Keeling FFR RCSIInterventional RadiologyNorthwestern University Medical SchoolChicago, IL, USA

K. Craig Kent MDProfessor of SurgeryColumbia Weill Cornell Division of Vascular SurgeryColumbia College of Physicians and SurgeonsWeill Medical College of Cornell UniversityNew York, NY, USA

George Kopchok BSBiomedical EngineerLos Angeles Biomedical Research Institute atHarbor UCLA Medical CenterTorrance, CA, USA

Christopher J. Kwolek MDProgram Director in Vascular SurgeryMassachusetts General HospitalDivision of Vascular and Endovascular SurgeryBoston, MA, USA

xvi    Contributors

Gregory J. Landry MDAssociate Professor of SurgeryDivision of Vascular SurgeryOregon Health and Science UniversityPortland, OR, USA

Peter F. Lawrence MDDirector, Gonda (Goldschmied) Vascular CenterWiley Barker Endowed Chair and Chief of Vascular Surgery David Geffen School of Medicine at UCLALos Angeles, CA, USA

Scott A. LeMaire MDProfessor and Director of ResearchDivision of Cardiothoracic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of Medicineand Cardiovascular Surgery StaffThe Texas Heart Institute at St. Luke’s Episcopal HospitalHouston, TX, USA

Peter H. Lin MDProfessor of SurgeryBaylor College of MedicineHouston, TX, USA

Evan C. Lipsitz MDAssociate Professor of SurgeryChief, Division of Vascular and Endovascular SurgeryMontefiore Medical Center and the Albert Einstein College of MedicineBronx, NY, USA

Bo Liu PhDAssociate ProfessorDepartment of SurgerySchool of Medicine and Public HealthUniversity of WisconsinMadison, WI, USA

Alan B. Lumsden MDProfessor of SurgeryWeill Medical College at Cornell UniversityNew York, NY;Chairman, Department of Cardiovascular SurgeryMedical DirectorMethodist DeBakey Heart and Vascular CenterHouston, TX, USA

Harry Ma MD, PhDVascular SurgeryTufts Medical CenterBoston, MA, USA

Robyn A. Macsata MD, FACSChief, Vascular SurgeryVeterans Affairs Medical CenterWashington DC, USA

Michel S. Makaroun MDDivision of Vascular SurgeryUniversity of Pittsburgh Medical CenterPittsburgh, PA, USA

Jesse M. Manunga, Jr. MDFellow, Division of Vascular and Endovascular SurgeryMayo ClinicRochester, MN, USA

Natalie Marks MD, RVTThe Vascular Institute of New YorkDivision of Vascular Surgery at Maimonides Medical CenterBrooklyn, NY, USA

Kenneth L. Mattox MDDistinguished Service ProfessorMichael E. DeBakey Department of SurgeryBaylor College of MedicineHouston, TX, USA

Manish Mehta MD, MPHAssociate Professor of SurgeryAlbany Medical College / Albany Medical Center HospitalThe Institute for Vascular Health and DiseaseAlbany, NY, USA

Charles C. Miller IIIFoster School of MedicineTexas Tech University Health Sciences CenterEl Paso, TX, USA

Yoshio Mishima MDProfessor and Chairman of SurgeryTokyo Medical and Dental UniversityTokyo, Japan

Lynn S. Model MDDepartment of SurgeryThe Yale University School of MedicineNew Haven, CT, USA

Takki A. Momin MDVascular Surgery FellowGeorgetown University / Washington Hospital CenterWashington DC, USA

Gregory L. Moneta MDProfessor of SurgeryChief, Division of Vascular SurgeryOregon Health Sciences UniversityPortland, OR, USA

Albeir Y. Mousa MDAssistant ProfessorDepartment of SurgeryRobert C. Byrd Health Sciences CenterWest Virginia UniversityCharleston, WV, USA

Contributors    xvii

Peter A. Naughton MDFellow, Vascular SurgeryNorthwestern University Medical SchoolChicago, IL, USA

Peter Neglen MD, PhDUniversity of Mississippi Medical Centerand River Oaks HospitalFlowood, MS, USA

Nicolas Nelken MDDivision of Vascular TherapyHawaii Permanente Medical GroupKaiser Foundation HospitalHonolulu, HI, USA

Richard F. Neville MD, FACSChief, Division of Vascular SurgeryProfessor of SurgeryGeorge Washington UniversityWashington, DC, USA

Audra A. Noel MDAssistant Professor of SurgeryMayo Medical SchoolConsultantDivision of Vascular SurgeryMayo ClinicRochester, MN, USA

Gustavo S. Oderich MDAssociate Professor of SurgeryConsultant, Saint Marys and Methodist HospitalDirector of Endovascular TherapyDirector of Edward Rogers Clinical Research Fellowship ProgramDivision of Vascular and Endovascular SurgeryMayo Clinic College of MedicineRochester, MN, USA

Kenneth Ouriel MDSyntactxNew York, NY, USA

William H. Pearce MDViolet R. and Charles A. Baldwin Professor of Vascular SurgeryDepartment of SurgeryNorthwestern University Medical SchoolChicago, IL, USA

Eric K. Peden MDAssistant Professor of SurgeryWeill Medical College at Cornell UniversityNew York, NY;Department of Cardiovascular SurgeryMethodist DeBakey Heart and Vascular CenterHouston, TX, USA

Bruce A. Perler MD, MBAJulius H Jacobson, II Professor of SurgeryChief, Division of Vascular Surgery & Endovascular TherapyJohn Hopkins UniversitySchool of MedicineBaltimore, MD, USA

Adam H. Power MDClinical Fellow in Vascular and Endovascular SurgeryDivision of Vascular and Endovascular SurgeryMayo Clinic College of MedicineMayo ClinicRochester, MN, USA

William J. Quinones-Baldrich MDProfessor of SurgeryDavid Geffen School of Medicine at UCLA;Director UCLA Aortic CenterRonald Reagan UCLA Medical CenterLos Angeles, CA, USA

Rodeen Rahbar MD, FACSAssistant Professor of SurgeryGeorge Washington UniversityWashington, DC, USA

Jeffrey K. Raines PhD, RVTDirector, Vascular Laboratory and ResearchMiami Vein CenterEmeritus Professor of SurgeryUniversity of Miami Miller School of MedicineMiami, FL, USA

Seshadri Raju MDProfessor Emeritus and Honorary SurgeonUniversity of MS Medical Center;Attending PhysicanRiveroaks HospitalFlowood, MS, USA

Jorge Rey MDThe Institute for Vascular Health and DiseaseAlbany Medical College / Albany Medical Center HospitalAlbany, NY, USA

John J. Ricotta MDChairman of SurgeryWashington Hospital Center and Georgetown UniversityWashington, DC, USA

Joseph J. Ricotta II MD, MSAssistant Professor of SurgeryDirector of Clinical ResearchDirector, International Clinical Research Fellowship in Vascular SurgeryAssociate Program Director, Vascular Surgery FellowshipDivision of Vascular Surgery and Endovascular TherapyEmory University School of MedicineAtlanta, GA, USA

xviii    Contributors

David A. Rigberg, MDAssociate Professor of SurgeryDavid Geffen School of Medicine at UCLALos Angeles, CA, USA

Sean P. Roddy MDAssociate Professor of SurgeryThe Institute for Vascular Health and DiseaseAlbany Medical CollegeAlbany Medical Center HospitalAlbany, NY, USA

Hazim J. SafiDepartment of Cardiothoracic and Vascular SurgeryThe University of Texas at Houston Medical SchoolMemorial Hermann Heart and Vascular InstituteHouston, TX, USA

Russell H. Samson MD, RVT, FACSClinical Associate Professor of Surgery (Vascular) and President, Mote Foundation IncFlorida State University Medical SchoolTallahassee, FL, USA

Richard J. Sanders MDClinical Professor of SurgeryUniversity of Colorado School of MedicineRose Medical CenterDenver, CO, USA

Sartaj S. Sanghera MDSurgical Oncology FellowRoswell Park Cancer InstituteBuffalo, NY, USA

Andres Schanzer MDAssociate Professor of SurgeryUniversity of Massachusetts Medical SchoolDivision of Vascular and Endovascular SurgeryWorcester, MA, USA

Harry Schanzer MD, FACSClinical Professor of SurgeryMount Sinai School of Medicine;Attending SurgeonMount Sinai HospitalNew York, USA

Peter A. Schneider MDDivision of Vascular TherapyHawaii Permanente Medical GroupKaiser Foundation HospitalHonolulu, HI, USA

Gary R. Seabrook MDProfessor of Vascular SurgeryMedical College of WisconsinMilwaukee, WI, USA

Amit R. Shah MDVascular SurgeonMontefiore Medical Center and the Albert Einstein College of MedicineBronx, NY, USA

Tejas R. Shah MDDepartment of SurgeryMount Sinai Medical CenterNew York, NY, USA

Jason P. Shaw MDAttending SurgeonDivision of Thoracic SurgeryMaimonides Medical CenterBrooklyn, NY, USA

Roy SheinbaumDepartment of Cardiothoracic and Vascular SurgeryThe University of Texas at Houston Medical SchoolMemorial Hermann Heart and Vascular InstituteHouston, TX, USA

Alexander Shiferson DODepartment of Vascular SurgeryMaimonides Medical CenterBrooklyn, NY, USA

Anton N. Sidawy MD, MPH, FACSProfessor and ChairmanDepartment of SurgeryGeorge Washington UniversityWashington, DC, USA

Michael B. Silva Jr MDThe Fred J. and Dorothy E. Wolma Professor in VascularSurgery and Professor of RadiologyChief, Division of Vascular Surgery and Endovascular TherapyDirector, Texas Vascular CenterThe University of Texas Medical BranchGalveston, TX, USA

Taylor A. Smith MDDivision of Vascular and Endovascular Surgery Ochsner Medical CenterNew Orleans, LA, USA

James C. Stanley MDHandleman Professor of SurgerySection of Vascular SurgeryUniversity of MichiganAnn Arbor, MI, USA

Yaron Sternbach MDAssociate Professor of SurgeryAlbany Medical College / Albany Medical Center HospitalThe Institute for Vascular Health and DiseaseAlbany, NY, USA

Contributors    xix

Jan J. Stokosa CP, FAAOPAmerican Prosthetic InstituteStokosa Prosthetic ClinicEast Lansing, MI, USA

David S. Sumner MDDistinguished Professor of SurgeryChief, Section of Peripheral Vascular SurgerySouthern Illinois University School of MedicineSpringfield, IL, USA

Bauer E. Sumpio MD, PhDProfessor and Vice Chairman of SurgeryChief, Vascular SurgeryYale University School of Medicine;Chief, Vascular ServiceYale–New Haven HospitalNew Haven, CT, USA

John B. Taggert MDAlbany Medical College / Albany Medical Center HospitalThe Institute for Vascular Health and DiseaseAlbany, NY, USA

Martin D. Tilson MDAilsa Mellon Bruce Professor of Surgery Columbia University;Director EmeritusDepartment of SurgerySt. Luke’s / Roosevelt HospitalNew York, NY, USA

William D. Turnipseed MDProfessor of SurgeryDivision of Vascular SurgeryUniversity of Wisconsin HospitalMadison, WI, USA

Frank J. Veith MD, FACSDivision of Vascular SurgeryNew York University Medical CenterNew York, NY;The Cleveland ClinicCleveland, OH, USA

Rodney A. White MDChief of Vascular SurgeryHarbor–UCLA Medical Center, Torrance, CA;Professor of Surgery, UCLA School of MedicineLos Angeles, CA, USA

Tze-Woei Tan MDFellow, Vascular SurgeryBoston Medical CenterBoston, MA, USA

Yeongchi Wu MDAssociate Professor of Physical Medicine and RehabilitationNorthwestern University Medical School;Director, Amputee RehabilitationRehabilitation Institute of ChicagoCenter for International RehabilitationChicago, IL, USA

List of Abbreviations

AAA abdominalaorticaneurysmAAAP-40 aorticaneurysm-associatedprotein40AASV anterioraccessorysaphenousveinABF aortofemoralbypassABI ankle-brachialindexABPI anklebrachialpressureindexACE angiotensin-convertingenzymeACP antegradecerebralperfusionACS acutecoronarysyndromesACT activatedclottingtimeADP adenosinediphosphateAER abductionexternalrotationAIOD aortoiliacocclusivediseaseALI acutelimbischemiaAMI acutemesentericischemiaAMP adenosinemonophosphateAMS absorbablemetalstentANA antinuclearantibodyAP ambulatoryphlebectomyAPC activatedproteinCAPG airplethysmographyApoA apoproteinAApoB apoproteinBaPTT activatedpartialthromboplastintimeARB angiotensin-receptorblockingagentASM anteriorscalenemuscleASO arteriosclerosisobliteransASVAL ambulatoryselectivevaricesablation

underlocalanesthesiaATIII antithrombinIIIATOS arterialthoracicoutletsyndromeATP adenosinetriphosphateAV arteriovenousAVA arteriovenousanastomosisAVF arteriovenousfistulaAVG arteriovenousgraftsAVM arteriovenousmalformationAVSS AberdeenvaricoseveinseverityscoreBAI bluntaorticinjuryBAM balloon-assistedmaturationBCS Budd–ChiarisyndromeBCVI bluntcerebrovascularinjurybFGF basicfibroblastgrowthfactorBIPAP bi-levelpositiveairwaypressure

xx

BMAC bonemarrowaspirateconcentrateBMS bare-metalstentBP bloodpressureBPA blood-poolcontrastagentsBRTO balloon-occludedretrograde

transvenousobliterationCA carotidartery,contrastangiographyCAA carotidarteryatherosclerosis,celiac

arteryaneurysmCABG coronaryarterybypassgraftCACS celiacarterycompressionsyndromeCAD coronaryarterydiseasecAMP cyclicadenosinemonophosphateCAS carotidarterystentingCBA cutting-balloonangioplastyCBP cardiopulmonarybypassCCA commoncarotidarteryCCS chroniccompartmentsyndromeCEA carotidendarterectomyCFA commonfemoralarteryCFDI colorflowdupleximagingcGFR calculatedglomerularfiltrationratecGMP cyclicguaninemonophosphateCGRP calcitoningene-relatedpeptideCHD coronaryheartdiseaseCHF congestiveheartfailureCIA commoniliacarteryCIN contrast-inducednephropathyCLI criticallimbischemiaCMI chronicmesentericischemiaCOPD chronicobstructivepulmonarydiseaseCPAP continuouspositiveairwaypressureCPB cardiopulmonarybypassCRI chronicrenalinsufficiencyCRP C-reactiveproteinCRPS complexregionalpainsyndromeCSF cerebrospinalfluidCT computedtomographyCTA computedtomographicangiographyCTO chronictotalocclusionCV contrastvenographyCVD cardiovasculardisease,chronicvenous

diseaseCVI chronicvenousinsufficiency

List of Abbreviations xxi

DA duplexarteriographyDAG diacylglyceroldAVF distalarteriovenousfistulaDES drug-elutingstentDHCA deephypothermiccirculatoryarrestDLT decongestivelymphatictherapyDR diameterreductionDSA digitalsubtractionangiographyDSE dobutaminestressechocardiographyDSRS distalsplenorenalshuntDTPA diethylenetriaminepentaaceticacidDUS duplexultrasoundDVP distalveinpatchDVT deepveinthrombosisDWI diffusion-weightedimagingDW-MR diffusion-weightedmagneticresonanceEAST elevatedarmstresstestEC endothelialcellECA externalcarotidarteryECG electrocardiogramECM extracellularmatrixEDRF endothelial-dependentrelaxingfactorEDS Ehlers–DanlossyndromeEDV end-diastolicvelocityEEG electroencephalogramEEL externalelasticlaminaEGF epidermalgrowthfactorEHIT endovenousheat-inducedthrombosisEIA externaliliacarteryELG endoluminalgraftELISA enzyme-linkedimmunosorbentassayeNOS endothelialnitricoxidesynthaseEPC endothelialprogenitorcellEPD embolicprotectiondevicesEPSF earlypostsurgicalfittingePTFE expandedpolytetrafluoroethyleneER-DP extended-releasedipyridamoleE-selectin endothelial-cellselectinESR erythrocytesedimentationrateESRD end-stagerenaldiseaseET endothelinEVAR endovascularaneurysmrepairEVL endovenouslaserEVPAR endovascularpoplitealarteryaneurysm

repairFAP femoralarterypressureFAK focaladhesionkinaseFDA FoodandDrugAdministrationFEP fluorinatedethylenepropyleneFEV1 forcedexpiratoryvolumeinonesecondFGF fibroblastgrowthfactorFOV fieldofviewFXII factorXIIG-6PD glucose-6-phosphatedehydrogenaseGA generalanesthesia

G-CSF granulocytecolony-stimulatingfactorGDAA gastroduodenalaneurysmGFR glomerularfiltrationrateGFV graftflowvelocityGRE gradientechoGSM grayscalemediumGSV greatsaphenousveinHAA hepaticarteryaneurysmHB-EGF heparin-bindingepidermalgrowth

factorHBOT hyperbaricoxygentherapyHCC hepatocellularcarcinomaHCI hypobariccompressioninterfaceHDL high-densitylipoproteinHGF hepatocytegrowthfactorHIF hypoxia-induciblefactorHIS hypobariccushioninterfacewith

integratedsuspensionHIT heparin-inducedthrombocytopeniaHLA humanleukocyteantigenHMVEC humanmicrovascularendothelialcellHMWK high-molecular-weightkininogenHO hemeoxygenaseHRE hypoxiaresponseelementHRS hepatorenalsyndromeHSC hematopoieticstemcellHSLW hemoglobin-specificlaserwavelengthsHU HounsfieldunitHUVEC humanumbilical-veinendothelialcellIAA iliacarteryaneurysmIBD iliacbrancheddeviceICA internalcarotidarteryICAM intercellularcell-adhesionmoleculeIDE investigationaldeviceexemptionIDL intermediate-densitylipoproteinIEL internalelasticlaminaIEUS intraoperativeepiaorticultrasoundIFN interferonIGF insulin-relatedgrowthfactorIH intimalhyperplasiaIIA internaliliacarteryIL-1 interleukin1IMA inferiormesentericarteryiNOS induciblenitricoxidesynthaseINR internationalnormalizedratioIP3 inositoltriphosphateIPG intraoperativepressuregradientIPSF immediatepostsurgicalfittingIPV incompetentperforatorveinsIVT ischemicvenousthrombosisIVUS intravascularultrasoundKTS Klippel–TrénaunaysyndromeLAO leftanteriorobliqueLDL low-densitylipoproteinLDL-C low-densitylipoproteincholesterol

xxii List of Abbreviations

LE lupuserythematosusLEDVT lower-extremitydeepveinthrombosisLEED linearendovenousenergydensityLHB leftheartbypassLIMA leftinternalmammaryarteryLL laparoscopiclysisLMWH low-molecular-weightheparinLR lactatedRinger’sLSV longsaphenousveinMACE majoradversecardiaceventsMALS medianarcuateligamentsyndromeMAPkinase mitogen-activatedproteinkinaseMCA middlecerebralarteryMCP-1 monocytechemoattractantprotein1MDCTA multidetectorcomputedtomographic

angiographyMEP motor-evokedpotentialMET metabolicequivalentMHC majorhistocompatabilitycomplexMI myocardialinfarctionMIP maximalintensityprojectionMMP matrixmetalloproteinaseMPA mycophenoleicacidMR magneticresonanceMRA magneticresonanceangiographyMRI magneticresonanceimagingMRV magneticresonancevenographyMSC mesenchymalstemcellMSM middlescalenemuscleMVT mesentericvenousthrombosisNIH neointimalhyperplasiaNIV noninvasiveventilationNIVL nonthromboticiliacveinlesionNO nitricoxideNOS nitricoxidesynthaseNP natureticpeptideNPMS neurogenicpectoralisminorsyndromeNRH nodularregenerativehyperplasiaNSF nephrogenicsystemicfibrosisNTOS neurogenicthoracicoutletsyndromeOLT orthotopiclivertransplantationPA poplitealarteryPAA poplitealarteryaneurysmPAAA para-anastomoticaorticaneurysmPACU post-anesthesiacareunitPAD peripheralarterialdiseasePAF platelet-activatingfactorPAI-1 plasminogenactivatorinhibitor1PAI-2 plasminogenactivatorinhibitor2PAPs percutaneousablationofperforatorsPC primaryclosurePCA patient-controlledanesthesiaPCD phlegmasiaceruleadolensPCI percutaneouscardiacinterventionPco2 partialpressureofcarbondioxide

PDAA pancreaticoduodenalaneurysmPDE5 phosphodiesterasetype5PDGF platelet-derivedgrowthfactorPE pulmonaryembolismPEEP positiveend-expiratorypressurePEG polyethyleneglycolPGI2 prostacyclinPHG portalhypertensivegastropathyPICA posteriorinferiorcerebellararteryPM pectoralisminorPMM pectoralisminormusclePMS pectoralisminorsyndromePMT pectoralisminortenotomy,percutaneous

mechanicalthrombectomyPOBA plainoldballoonangioplastyPPAR peroxisomeproliferator-activated

receptorPPC postoperativepulmonarycomplicationsPPG photoplethysmographyPRF pulse-repetitionfrequencyPSGL-1 P-selectinglycoproteinligand1PSS Paget–SchroettersyndromePSV peaksystolicvelocityPTA percutaneoustransluminalangioplastyPTCV posteriorthighcircumflexveinPTFE polytetrafluoroethylenePTPS posttraumaticpainsyndromePV perforatorveinPVR pulse-volumerecordingQSART quantitativesudomotoraxonreflextestQST quantitativesensorytestingRA renalartery,regionalanesthesiarAAA rupturedabdominalaorticaneurysmRAFT radialarteryflow-throughRAR renalaorticratioRCP retrogradecerebralperfusionRCT randomizedcontrolledtrialRFA radiofrequencyablationRI resistiveindexRIMA rightinternalmammaryarteryRP retroperitonealRRD removablerigiddressingRSD reflexsympatheticdystrophyRSRI renalsystemicreninindexrtPA recombinanttissueplasminogen

activatorRV renalvein,residualvolumeRVRR renalveinreninratioRVT registeredvasculartechnologistRVU relativevalueunitsSA subclavianarterySAA splenicarteryaneurysmSCF stemcellfactorSCI spinalcordinjurySCM sternocleidomastoid

List of Abbreviations xxiii

SDF stroma-derivedfactorSEPS subfascialendoscopicperforatorsurgerySFA superficialfemoralarterySFJ saphenofemoraljunctionSFJT saphenofemoraljunction

thrombophlebitisSIA subintimalangioplastySIP sympatheticallyindependentpainSMA superiormesentericarterySMAA superiormesentericarteryaneurysmSMC smoothmusclecellSMP sympatheticallymaintainedpainSNR signal-to-noiseratioSSEP somatosensory-evokedpotentialSSFP steady-statefreeprecessionSSV shortsaphenousveinSSVT suppurativesuperficialvenous

thrombophlebitisSVC superiorvenacavaSVC-GF superiorvenacavaGreenfieldfilterSVR superficialvenousrefluxSVT superficialvenousthrombophlebitisTAA thoracicaorticaneurysmTAAA thoracoabdominalaorticaneurysmTAO thromboangiitisobliteransTASC TransAtlanticIntersocietyConsensusTBPI toebrachialpressureindexTCD transcranialDopplerTcPo2 transcutaneousoxygentensionTE echotimeTEA transaorticendarterectomyTEE transesophagealechocardiographyTEVAR thoracicendovascularaneurysmrepairTF tissuefactorTGF transforminggrowthfactorTIA transientischemicattackTIMP tissueinhibitorofmetalloproteinasesTIPS transjugularintrahepaticportosystemic

shuntTMJ temporomandibularjoint

TNF-α tumornecrosisfactoralphaTOS thoracicoutletsyndromeTP transperitonealtPA tissueplasminogenactivatorTR repetitiontimeTRAK time-resolvedangiographyusing

keyholeTREATS time-resolvedecho-sharedangiography

techniqueTRICKS time-resolvedimagingofcontrast

kineticsTriVex transilluminatedpowered

phlebectomyTVS temporaryvascularshuntsUEDVT upper-extremitydeepveinthrombosisUFH unfractionatedheparinUGFS ultrasound-guidedfoamscleropathyUGS ultrasound-guidedsclerotherapyUK urokinaseULTT upperlimbtensiontestuPA urokinaseplasminogenactivatorUS ultrasoundVAA visceralarteryaneurysmVAS visualanaloguescaleVBI vertebrobasilarischemiaVCAM vascularcell-adhesionmoleculeVEGF vascularendothelialgrowthfactorVH virtualhistologyVI vascularinnovationVLA-4 very-lateformingantigen4VLDL very-low-densitylipoproteinVM vascularmalformationVOD veno-occlusivediseaseV/Q ventilationperfusionVTE venousthromboembolicdiseaseVTOS venousthoracicoutletsyndromeWBC whitebloodcellWHVP wedgedhepaticveinpressureWSLW water-specificlaserwavelengthsXRT radiationtherapy

PART IVascular Imaging Techniques and Physiologic Testing

CHAPTER 1

Arterial and Venous Duplex Scanning

Gregory L. MonetaOregon Health and Science University, Portland, OR, USA

The noninvasive vascular laboratory provides the scien-tific basis for vascular surgery. It safely provides accu-rate and quantitative evidence of the presence and physiologic significance of arterial and venous disease. In the modern vascular laboratory ultrasound-based techniques, particularly duplex ultrasound techniques, are most extensively employed.

Ultrasound basics

Duplex ultrasound was introduced in 1974 with appli-cation to the carotid artery. “Duplex” indicates the tech-nique combines B-mode imaging and Doppler analysis of blood-flow direction and velocity. It is extensively utilized for evaluation of carotid arteries, intra-abdominal arteries and veins, and upper- and lower-extremity arteries and veins. Since its inception, engineering and software advances have been extensive and include: 1) improved gray-scale B-mode imaging, 2) low-frequency scan heads permitting deep penetra-tion of the ultrasound beam from the skin surface, 3) improvements in online computer-based microprocess-ing, and 4) addition of color-flow imaging.

Color flow is a superimposed real-time colorized image of blood flow onto a standard gray-scale B-mode picture. Echoes from stationary tissues generate B-mode images, whereas those interacting with moving sub-stances (blood) generate a phase shift that is processed separately and color coded to give information on the direction and velocity of blood flow that reflects the magnitude and direction of the Doppler shift. Color flow dramatically reduces the time required to perform duplex examinations by allowing more rapid identifica-tion of vessels to be examined. It appears essential for duplex examination of some vessels, such as tibial arter-ies and veins. Color flow and the ability of modern duplex scanners to detect blood flow velocities <5 cm/s

Haimovici’s Vascular Surgery, Sixth Edition. Edited by Enrico Ascher, Frank J. Veith, Peter Gloviczki.© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

3

make duplex scanning practical in virtually all areas of the body.

Basics of duplex ultrasound

A vibrating source produces an ultrasonic wave. In duplex ultrasound the vibrating source is the trans-ducer. Ultrasound transducers are contained within scan heads. Scan heads steer and focus the sound beam produced by the transducer. The ultrasound image is derived from the returning echoes and is dependent on precise steering and focusing of the sound beam.

Transducers convert electrical into vibrational energy to produce the ultrasound wave. Transducers can also convert vibrational energy of returning echoes into elec-trical signals for analysis by the duplex machine’s soft-ware. The frequency of the vibration is determined by the design of the transducer and determines the wave-length of the sound wave. Frequency and wavelength are related, λ = c/f, where λ is the wavelength, c is the speed of sound in tissue, and f is the frequency.

Speed of sound in soft tissues averages 1540 m/s. There is little variation in the soft tissues insonated in clinical use of duplex ultrasound. Wavelength is the principle determinant of how well an ultrasound beam penetrates tissue, and wavelength depends on the fre-quency of the transducer. The transducer frequency is determined by the design of the transducer and is thus controlled by the manufacturer. For examination of the carotid artery, transducer frequencies of 5 to 7.5 MHz provide optimal tissue penetration for clinical purposes.

As noted above, duplex refers to the combination of Doppler and B-mode (“B” stands for “brightness”) ultrasound in the same device. Both require analysis of reflected echoes of the original sound beam created by the ultrasound transducer. B-mode analyzes the strength

4 Chapter 1

The strength of the ultrasound beam at a specific point also depends on how much the beam has been attenuated passing through tissue. Attenuation depends upon both the tissue traversed and the frequency of the wave. Wave frequency depends upon the frequency of the transducer generating the wave (see discussion above and Equation 1). Higher-frequency sound waves are attenuated more rapidly than lower-frequency sound waves. Higher-frequency transducers therefore provide relatively weak echoes to be reflected from a deep structure. The image generated is comparatively poor compared with a lower-frequency transducer insonating a deeper structure.

Image quality also depends upon linear resolution. Linear resolution is dependent upon the ability to focus the beam. High-frequency sound waves are better focused than sound waves from low-frequency trans-ducers and provide sharper and better quality B-mode images. Image quality is therefore a balance of the strength of the reflected echo and the ability to focus the sound beam. The carotid artery is superficial and higher-frequency transducers can be used to provide clear B-mode images. (Fig. 1.1A and B) Image quality is less when examining deep vessels such as renal or iliac arteries.

Doppler ultrasound

Continuous wave Dopplers have transducers that con-tinually emit vibrations into tissue. Therefore, echoes are also continually reflected back to the transducer. Transducers cannot generate and receive echoes simul-taneously. A continuous wave Doppler therefore must have separate transmitters and receivers to generate and receive echoes.

Duplex devices utilize pulse Doppler. Pulse Dopplers use a single transducer to generate and receive echoes. With a pulse Doppler it is possible to know when an

(intensity) and origin of the reflected echo. Doppler analyzes shifts in frequency of the original sound wave produced by the transducer.

B-mode ultrasound

As a sound wave passes through tissue and moves away from the transducer its strength depends upon how much the beam is scattered, attenuated, and reflected. Strength of reflected echoes depend, in part, upon dif-ferences in acoustic impedance between media. When there are major differences in acoustic impedance a large proportion of the sound beam is reflected back to the transducer. Small differences in acoustic impedances result in little reflection and the beam continues to prop-agate through the tissue.

In B-mode ultrasound, the brightness of the individ-ual pixels comprising the ultrasound image is propor-tional to the strength of the returning echo. This is the ultrasound gray scale, and the resulting image is termed a gray-scale image. Very bright pixels in the gray-scale image indicate large differences in acoustic impedance between media. Less dramatic differences are repre-sented by proportionally less-bright pixels. Thus gall-stones, with dramatic differences in acoustic properties from soft tissue, produce strong echoes and proportion-ally very bright pixels on the ultrasound image, whereas blood, which differs little from soft tissue in acoustic characteristics, often cannot be distinguished from soft tissue with B-mode imaging.

The strength of the reflected echo is also dependent upon the strength of the sound beam at the point where it is relected. Gray-scale images represent the absolute strength of the reflected echo arriving back at the trans-ducer, not the percentage of the beam reflected. There-fore, if the sound beam is very weak at the point of reflection even areas of dramatic acoustic differences will not result in a bright pixel in the B-mode image.

Figure 1.1 Gray-scale images of (A) mildly and (B) severely diseased bifurcations of the cervical carotid artery.

A B