Over the past 50 years, the discipline of vascular surgery has witnessed a rapid proliferation and remarkable progress in technique, technology, and research. Advances in anesthesia and perioperative care have further improved mortality and morbidity. In the past 2 decades, endovascular therapy has become a fundamental part of the vascular specialist's practice, and evidence-based studies have provided improved data to formulate standards of care. The end result has been improvement in the clinical care of patients. This chapter limits itself to four topics in vascular surgery: (1) carotid revascularization; (2) upper extremity revascularization; (3) management of aortoiliac disease and lower extremity revascularization; and (4) upper and lower extremity venous thrombosis.
Although the percentage of deaths resulting from stroke continues to decrease over time, stroke remains the third leading cause of death in the United States, with a mortality of approximately 45 deaths among a population of 100,000 people. The incidence is increasing, with nearly 800,000 new cases per year in the United States.1 Substantial morbidity also results from stroke, as approximately 31% of all stroke patients require outpatient rehabilitation; furthermore, >18% of patients are unable to return to work.2 Overall, the national 2009 direct and indirect estimate of cost of stroke is $68.9 billion, most of which results from a loss of earnings due to the disability of stroke.1
Approximately 15% to 20% of strokes originate from carotid atherosclerotic plaques, emboli, or thombi.3 There are several preoperative imaging modalities available to evaluate the carotid circulation. Arteriography remains the gold standard of preoperative imaging for carotid artery disease; however, due to the intrinsic stroke risk (0.7%-1.2%)4,5 and cost, arteriography is being used less frequently.3 Instead, vascular surgeons rely on duplex ultrasound alone6 or in conjunction with computed tomography angiography (CTA) and magnetic resonance angiography (MRA).3 Noninvasive studies fail to elucidate all carotid stenoses accurately; therefore, we use carotid angiography when there is:
- Uncertainty about the accuracy or reliability of the vascular ultrasound results
- Uncertainty about the possibility of complete occlusion of the carotid artery in a patient with ongoing localizing symptoms
- Concern about proximal or intrathoracic disease
- A patient with technically difficult studies caused by variant arterial anatomy
- A patient with symptoms and an indeterminate noninvasive study
Carotid endarterectomy (CEA) remains the most frequently performed procedure to prevent stroke, with approximately 99,000 operations performed in 2006.1 The operation can be performed under local anesthesia, cervical block, or general anesthesia. Although general anesthesia has the advantage of improved airway control and patient comfort, it does require the use of routine or selective shunting (Fig. 110–1). Selective shunting may involve the use of intraoperative electroencephalography,7 measurement of internal carotid artery stump pressures, or transcranial Doppler ultrasound to assess the need for a shunt.
Indwelling shunt in place to ...