05th October, 2015

Zoltán Szeberin

Dept. of Vascular Surgery

Vascular surgery

Venous insufficiency

Aneurysms

Vascular surgery

Arterial diseases

Venous diseases

Potencially life

threatening

diseases

Prevalence is high

Venous diseases

Varicose veins

• Why is this important?

• More than half of the adult population is

affected

• Danger? Thrombophlebitis, thrombosis

• Risk factors: age, obesity, immobility,

smoking, malignant tumor, congenital

thrombotic predisposition, job, gravidity

Venous diseases

Varicose veins

Venous diseases

Varicose veins

-Dilatation of the superficial veins

-Veins: capacious, thin walled blood vessels

-70% of total blood volume

-Upright position

Superficial veins of the leg

Venous diseases

Varicose veins

• Bicuspid valves are responsible for

unidirectional flow

• Muscle pump

• Superficial and deep system

• Perforant veins

Venous valves (US)

Chronic Venous Disease

Venous diseases

Varicose veins

Symptoms

• Cosmetic, pain, inflammation, leg ulcer,

rupture

• Diagnosis:

– Inspection

– Doppler ultrasound

– Duplex US

Venous diseases

Deep vein incompetency

• Retrograde flow in deep veins

• Possible complications :

– crural ulcer

– thrombosis

• Etiology:

– thrombosis

– congenital

CT venography

CT venography

CT venography

Abdominal wall venous collaterals

MR venography

MR venography

Chronic VCI occlusion

Diagnostics

• Venography is recommended in patients

with post-thrombotic disease, especially if

intervention is planned. (?)

• Ascending venography with injection of

contrast material into the foot. (additional

transfemoral injection)

Venography, history?

Venography, history?

Venography

Retroperitoneal fibrosis (stent)

CVI, repeated pulmonary

embolism, VCI filter

CVI prevention

Lysis of AVI

Lysis method • local lysis (CDT)- tPA : 20 mg bolus, than 2-3 mg/h perfusion and

5000 IU Na-heparin bolus, than 500-1000 IU/h (aPTI: 1,5-2,5x)

• Trombus aspiration (e.g. Angiojet, Angiovac)

• Dilatation or stent if necessary (chronic stenosis on control AG)

.

Control phlebography - Stent

Chronic VCI occlusion

The ideal treatment of varicosity -painless

-no narcosis or peridural anaesthesia

-one step procedure

-quick return to work

-excellent cosmetic results

-no complications

Stripping of LSV

Stripping of LSV

Stripping of LSV

High ligation GSV

Endoscopic perforator surgery

Method of perforator ablation

Endoscopic surgery

Cryo-stripping

Endovenous laser treatment

Radiofrequency ablation

Puncture with ultrasound

Tumescent anesthesia in varicose vein

surgery

The ideal treatment of varicosity painless procedure

no anaesthesia needed

excellent cosmetic results

no complications

simple

cheap

Venous diseases

Varicose veins

• Results

– 10-15 % recurrent

• Postop. treatment

– Compression stockings

– Lifestyle, sports

– Drugs to improve vein wall strength (pills, ointments)

Venous diseases - complications

Thrombophlebitis (spf.)

• Painful, slowly healing disease

• Conservative treatment:

– Salicyl acid

– Elastic bandage, compression stockings

– Activity advice

– Antibiotics

• Surgery: Ligation (ascending phlebitis)

Venous diseases - complications

Varicose vein rupture • Frightening, but benign

symptoms

• Treatment:

horizontal position,

elevation of the extremity,

compression dressing, suture at a vascular surgical clincic or ward

Pulmonary embolisation

• Therapy

– Heparin, Syncumar

– Lysis (tissue plazminogen activator)

– Surgery (sternotomy, card. pulm. bypass,

thrombectomy)

Pulmonary embolisation

• High mortality

2005 USA 200 000 patient

10% died

Cause: most commmonly deep vein thrombosis of the lower extremity

• Prevention:

– Early mobilisation

– Active compression

– Heparin

AAA

AAA

What is an aneurysm?

• Circumscribed dilatation of an artery,

containing blood or thrombus.

• The diameter is more than 1.5 times

bigger than normal vessel size.

Are aneurysms rare?

• Aneurysm related mortality is 15 000

patient/ year in the U.S.

47

AAA

AAA

AAA

50

AAA

• Mortality of elective aneurysm < 5%

• Ruptured cases ~ 50%

History - AAA London Guy Hospital 1817 - Sir Astley Cooper

52

History - AAA

• 1951, Charles Dubost in France performed

the first successful resection of an

abdominal aortic aneurysm and replaced it

with a cadaver homograft, initiating the

modern era of surgical correction of

aneurysm.

Open surgery

AAA

AAA

AAA

Stentgraft implantation

58

Stentgraft implantation

59

CT angio

60

Stentgraft in the aneurysm sac

61

Stentgraft

AAA complications

• - bleeding

• - thrombotic

occlusion

• - embolization

• - compression of

nearby organs

Aneurysm rupture

64

Aneurysm rupture

Contained rupture

Rupture to abdominal cavity

Retroperitoneal rupture

Screening

Screening

• Screening of elderly men

• Efficacy?

67

Genetic research

• Hereditary diseases of connective tissue

disorders

• Marfan syndrome

68

Medical treatment

• Antihypertensives

• Antibiotics

• Green tea

• Turmeric powder

– (curcumin)

69