This document is an introduction to the European Manual of Medicine: Vascular Surgery. It provides a brief history of vascular surgery in Europe, highlighting pioneers from different countries. It also discusses the development of atherosclerosis and the role of lipids in peripheral arterial disease. The introduction aims to give context to the manual and orient the reader to the scope and content covered.

2. European Manual of Medicine Vascular Surgery
C. D. Liapis
Chief Editor
K. Balzer, F. Benedetti-Valentini,
J. Fernandes e Fernandes
Editors

3. Editors C. D. Liapis,
K. Balzer,
F. Benedetti-Valentini,
J. Fernandes e Fernandes
Vascular Surgery
With 385 Figures and 58 Tables
123

4. Series Editors Volume Editors
Wolfgang Arnold, MD Christos D. Liapis, MD, FACS, FRCS
HNO und Poliklinik Department of Vascular Surgery
Klinikum rechts der Isar Athens University Medical School
München Attikon University Hospital
Germany Athens
Greece
Uwe Ganzer, MD
HNO und Poliklinik Klaus Balzer, MD
Heinrich-Heine-Universität Division of Vascular Surgery
Düsseldorf Evangelisches Krankenhaus
Germany Mülheim
Germany
Fabrizio Benedetti-Valentini, MD
Department of Vascular Surgery
University of Rome „La Sapienza“
Rome
Italy
José Fernandes e Fernandes, MD, PhD
Chief of Service
Department of Vascular Surgery
Hospital Santa Maria and Faculty of Medicine
Director Instituto Cardiovascular de Lisboa
Lisbon
Portugal
ISBN-10 3-540-30955-1
Springer Berlin Heidelberg NewYork
ISBN-13 978-3-540-30955-0
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5. V
Acknowledgements
When the invitation came from Springer-Verlag to produce this first European
manual of vascular surgery, it was accepted enthusiastically by the editors, al-
beit with some trepidation concerning the demands of such a venture. This
concern was due to the diverse nature of the vascular system, which covers
every part of the human body; therefore, diseases of the vascular system affect
all organs and all parts of the human anatomy and in order to provide a thor-
ough perspective on the discipline of vascular surgery, the manual would have
to cover the full spectrum of vascular diseases.
However, the pressing need to produce a long-overdue European manu-
al on vascular surgery was the driving force that brought together several of
the finest minds in Europe, who so generously accepted the task of imparting
their expert knowledge by contributing chapters in their own specific areas.
The diversity of the discipline, coupled with the differences in management
of vascular diseases by authors originating from different European countries,
required the work to be carefully formatted to render it an effective reference
book, based on recommended European standards for professionals and train-
ees with a common goal: optimum care of the vascular patient.
The editors are deeply grateful to the distinguished authors and all their
associates involved in this compilation. Apart from these tremendous contri-
butions, this project would not have been possible without the enormous as-
sistance of my associate Dr. Yannis Kakisis and the invaluable cooperation of
Ms. Gabriele Schroeder and Ms. Waltraud Leuchtenberger of Springer-Verlag,
Patrick Waltemate of LE-TeX and my administrative assistant Ms. Vivienne
Rose.
We hope the readership will benefit from this first European Manual of
Medicine: Vascular Surgery.
The editors
Christos D. Liapis
Klaus Balzer
Fabrizio Benedetti-Valentini
José Fernandes e Fernandes

7. VII
Foreword
Gregory D. Skalkeas
Professor Emeritus, Academician,
President of the Foundation of Biomedical
Research of the Academy of Athens
Vascular surgery has acquired a well-established identity throughout the Euro-
pean Union, where vascular diseases are still the leading cause (40%) of death
and disability.
Proper management of vascular diseases is dependent on public awareness
and appropriate training of specialists. This stands true for every medical dis-
cipline. For vascular surgery it has an additional aspect because, besides the
required above-average standard of technical dexterity, the vascular surgeon
should also be well versed in a variety of subjects such as molecular biology, in
the use of ultrasound and – with the introduction of endovascular techniques
– a skilful operator of guidewires and laparoscopic instruments. All the accu-
mulated know-how and skills required for proper management of the vascular
patient demand a rapid change in the training of vascular surgeons and an in-
depth knowledge of the various manifestations of vascular diseases.
The information necessary for the above is disseminated through books,
journals and the internet. Most of the time, however, articles in journals reflect
the experience and enthusiasm of the authors on the subject but not the level
of knowledge of the medical community as a whole. Electronic information is
fast and reliable but always gives the reader the impression of being short-lived.
Books, on the other hand, allow a reflection of what has been written and a true
interactive role for the reader.
Multi-author books have the inherited handicap of not conveying a specific
message by virtue of the diversity of thought; however, when the authors hap-
pen to be experts in their field and to represent most of the countries within the
European Continent that is striving to prove its successful function as a union,
then such a collaboration can indeed convey a message: the level of knowledge
and the modus vivendi of vascular surgery in Europe.
The editor and authors of this compilation are to be congratulated for such
an endeavour, worthy of the European spirit of unity and collaboration.

9. IX
Preface
Sir Peter Bell
Professor of Surgery, University of Leicester
European Manual of Medicine: Vascular Surgery
Vascular surgery has evolved and expanded in a spectacular fashion during the
last 50 years. During this time previously untreatable conditions have become
treatable and dealt with on a regular basis by vascular surgeons. Many of the
pioneers of vascular surgery were from Europe, starting with Cid Dos Santos
who invented angiography and made the whole field of vascular surgery pos-
sible. Jean Kunlin in 1949 was the first surgeon to use a reversed vein by-pass
graft successfully. In the field of aortic surgery, Lerich and Matas were pio-
neers in this area and Felix Eastcott started the long and successful treatment
of carotid artery stenosis by surgery. Successive generations of Europeans have
continued to be involved in the evolution of vascular surgery, taking it to a new
phase of activity. European surgeons continue to be at the forefront of changes
in vascular practice and have made it possible for the new era of laparoscopic
and endovascular surgery to progress and flourish.
One might ask why we need yet another textbook of vascular surgery. This
is a perfectly reasonably question and the answer is because no book exists that
offers comprehensive knowledge, both theoretical and practical, to every level
of vascular surgeon. Buying books is expensive and it is therefore important
that such books are of use to all of those who may wish to read them. The aim
of this book is to be as useful to the vascular trainee as to the established vas-
cular consultant. To this end the editors have enlisted and given a clear brief
to leading practitioners in the field. All of the topics that one would normally
expect to see in such a book are included and the text is sufficiently referenced
to make it authoritative. Pictures and figures are also used but not extensively
and are not a major selling point of this volume. The theoretical and practi-
cal aspects of open surgery, endovascular procedures and laparoscopic surgery
are all covered in detail and venous disease and lymphatic problems are not
ignored.
One question that might be asked is: why are all the contributing surgeons
from Europe and none from other countries or continents? This is intentional
and not xenophobic, but an attempt to show that the necessary expertise to
cover all aspects of the practice of vascular surgery exists in the expanded Eu-
ropean community. It is also to acknowledge the fact that vascular procedures
and practice are not necessarily the same the world over. The approach to some
problems is different in Europe than it is in other continents and these differ-
ences are reflected in this book. I am sure that those who buy and read this
book will not be disappointed in its content or style. It will be extremely useful
to all readers and be a signpost to the future of vascular surgery.

11. XI
Introduction
Christos D. Liapis, John D. Kakisis
Vascular diseases are the most frequent cause of death and disability of Eu-
ropeans. The aim of the present book, European Manual of Medicine: Vascu-
lar Surgery, is to give an indication of European standards for the diagnosis
and therapy of vascular diseases. It is designed with the same format as other
books in the series European Manuals of Medicine and focuses on the descrip-
tion of each clinical entity (definition, epidemiology, aetiology, symptoms and
complications) and on the recommended European standard diagnostic and
therapeutic steps. In contrast to other textbooks, most of the information is
presented in bulleted listings instead of lengthy paragraphs. This is done in the
hope of enabling the reader to retrieve information easily and quickly.
The first chapters of this book refer to the pathogenesis of vascular diseases,
including the development of atherosclerosis and the effect of dyslipidaemia,
clotting disorders and emerging biochemical risk factors. Subsequent chapters
present the noninvasive and invasive means of diagnosis, including latest de-
velopments such as computer-guided diagnosis of vascular diseases. The pre-
operative evaluation and optimization as well as the peri-operative care of the
vascular patient are also discussed. The book includes a review of the history of
vascular surgery in Europe and a chapter on the training of vascular surgeons
for endovascular procedures in order to highlight the continuity and the prog-
ress of vascular surgery over the past century and the future perspectives. The
chapters of the book cover the entire range of arterial, venous and lymphatic
disorders with an emphasis on all recent developments including endovascular
and laparoscopic surgery. The text is comprehensive since the book is intended
not only for vascular specialists but also for students, residents in vascular sur-
gery and other interested physicians.
The chapters have been written mainly by national representatives on the
newly established Section of Vascular Surgery of the European Union of Medi-
cal Specialists (UEMS), thus drawing upon the collective experience of vascu-
lar surgeons/specialists from the various European countries. The authors are
experts in their field, providing the reader with a professional opinion reflect-
ing what is generally considered to be the state-of-the-art in each area.
We hope that the readers, especially the hard working trainees in vascular
surgery to whom this book is dedicated, will find it useful.

13. XIII
Contents
Vascular Surgery and the Vascular Patient 1.2.2.2 Initiation of Atherosclerosis
and Role of Endothelial
1.1 The History of Vascular Surgery Dysfunction . . . . . . . . . . . . . . . . . . . . . . 23
in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2.2.3 Evolution of the Atherosclerotic
1.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 3 Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.1.2 The Origin and the Foundations 1.2.3 Contributive Factors
of European Vascular Surgery . . . . . . . 3 to Endothelial Dysfunction
1.1.3 Europe, Cradle of the World’s and Plaque Formation . . . . . . . . . . . . . 28
Vascular Surgery . . . . . . . . . . . . . . . . . . . 7 1.2.3.1 Miscellaneous Factor . . . . . . . . . . . . . . 28
1.1.3.1 The Nursery of Vascular Surgery 1.2.3.2 The Oxidized LDL Hypothesis . . . . . . 28
in Europe in the 1930s was 1.2.4 Plaque Instability
the René Leriche School in and Complicated Plaques . . . . . . . . . . 30
Strasburg, France . . . . . . . . . . . . . . . . . . 8 1.2.5 Classification of Atherosclerotic
1.1.3.2 Reference to European Surgeons Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
who Through their Pioneering 1.2.6 Assessment and Evaluation
Work Developed Vascular of the Risk of an Atherosclerotic
Surgery in their Continent with Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
International Influence . . . . . . . . . . . . 10 1.2.7 General Therapeutic Measures . . . . . 31
1.1.3.3 Medical and Interventional 1.2.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 32
Vascular Contributions to References . . . . . . . . . . . . . . . . . . . . . . . . 32
the Development of Vascular
Surgery in Europe and Worldwide . . 12 1.3 Lipids and Peripheral Arterial
1.1.4 European Vascular Surgical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
and Angiological Societies and 1.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 35
Congresses . . . . . . . . . . . . . . . . . . . . . . . 14 1.3.2 Effect of Lipid Lowering on PAD . . . 35
1.1.5 Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.3.2.1 Prevention of PAD . . . . . . . . . . . . . . . . 35
Acknowledgements . . . . . . . . . . . . . . . 19 1.3.2.2 Improvement of Symptoms
References . . . . . . . . . . . . . . . . . . . . . . . . 20 Associated with PAD . . . . . . . . . . . . . 35
1.3.2.3 Reduction of the Risk of
1.2 Development of Atherosclerosis Vascular Events Associated with
for the Vascular Surgeon . . . . . . . . . . . 23 PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . 23 1.3.3 Peripheral Vascular Surgery and
1.2.2 Physiopathology of Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Atherosclerosis . . . . . . . . . . . . . . . . . . . 23 1.3.4 Additional Potential Actions
1.2.2.1 Normal Blood Vessel of Lipid-lowering Drugs
Morphology . . . . . . . . . . . . . . . . . . . . . . 23 that may Benefit PAD Patients . . . . . 37
1.3.5 Are all Statins the Same? . . . . . . . . . . . 37

14. XIV Contents
1.3.6 Concluding Comments . . . . . . . . . . . . 37 1.6 Invasive Diagnosis of Vascular
References . . . . . . . . . . . . . . . . . . . . . . . . 38 Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 65
1.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 65
1.4 Clotting Disorders: What Should 1.6.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
the Vascular Surgeon Know 1.6.3 Arteriography . . . . . . . . . . . . . . . . . . . . . 68
About Hypercoagulation States 1.6.3.1 Techniques . . . . . . . . . . . . . . . . . . . . . . . 68
in Venous Diseases? . . . . . . . . . . . . . . . 41 1.6.3.2 Pre-procedure Evaluation
1.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 41 and Preparation . . . . . . . . . . . . . . . . . . . 69
1.4.2 Venous Thrombosis . . . . . . . . . . . . . . . 41 1.6.3.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . 69
1.4.2.1 Risk Factors . . . . . . . . . . . . . . . . . . . . . . 41 1.6.3.4 Post-procedure Care . . . . . . . . . . . . . . . 70
1.4.3 What Should a Surgeon do when 1.6.3.5 Complications . . . . . . . . . . . . . . . . . . . . 70
Faced with Hypercoagulation? . . . . . 45 1.6.3.6 Direct Toxicity . . . . . . . . . . . . . . . . . . . 71
1.4.3.1 Should a Search for 1.6.4 Phlebography . . . . . . . . . . . . . . . . . . . . . 72
Thrombophilia be Undertaken? . . . . 45 1.6.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . 72
1.4.3.2 How Should the Search 1.6.4.2 Techniques . . . . . . . . . . . . . . . . . . . . . . . 72
be Done? . . . . . . . . . . . . . . . . . . . . . . . . . 45 References . . . . . . . . . . . . . . . . . . . . . . . . 74
1.4.3.3 Diagnosing Thrombotic Disease
in Patients with Thrombophilia . . . . . 46 1.7 Computer-Aided Diagnosis
1.4.3.4 Treating Thromboembolic of Vascular Disease . . . . . . . . . . . . . . . . 77
Disease in Patients 1.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . 77
with Thrombophilia . . . . . . . . . . . . . . 46 1.7.2 Computer-Aided Diagnosis
1.4.3.5 Specific Considerations in Vascular Imaging . . . . . . . . . . . . . . . 77
in Treating Thromboembolic 1.7.2.1 Image Pre-processing . . . . . . . . . . . . . . 78
Disease Related to Thrombophilia . . 46 1.7.2.2 Definition of Regions of Interest
1.4.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . 47 – Automatic Segmentation . . . . . . . . . 78
References . . . . . . . . . . . . . . . . . . . . . . . 47 1.7.2.3 Extraction and Selection
of Characteristic Features . . . . . . . . . 78
1.5 Noninvasive Diagnosis 1.7.2.4 Classification . . . . . . . . . . . . . . . . . . . . . 80
of Vascular Diseases . . . . . . . . . . . . . . . 51 1.7.2.5 ANALYSIS: a Modular Software
1.5.1 Peripheral Arterial Disease . . . . . . . . . 51 System to Support Diagnosis
1.5.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 51 of Vascular Disease . . . . . . . . . . . . . . . . 81
1.5.1.2 Physical Examination . . . . . . . . . . . . . . 51 1.7.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 82
1.5.1.3 Basic Haematological References . . . . . . . . . . . . . . . . . . . . . . . 82
and Biochemical Tests . . . . . . . . . . . . . 51
1.5.1.4 Special Investigations, Other 1.8 Preoperative Evaluation
Than Imaging . . . . . . . . . . . . . . . . . . . . . 51 of a Vascular Patient . . . . . . . . . . . . . . . 85
1.5.1.5 Imaging Techniques . . . . . . . . . . . . . . . 54 1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 85
1.5.1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 55 1.8.2 Systemic Evaluation . . . . . . . . . . . . . . . 85
1.5.2 Disease of Arteries Supplying 1.8.2.1 Cardiovascular System . . . . . . . . . . . . . 85
the Brain . . . . . . . . . . . . . . . . . . . . . . . . . 56 1.8.2.2 Respiratory System . . . . . . . . . . . . . . . . 86
1.5.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 56 1.8.2.3 Renal System . . . . . . . . . . . . . . . . . . . . . 88
1.5.2.2 Imaging Techniques . . . . . . . . . . . . . . . 56 1.8.3 Evaluation of Specific Vascular
1.5.2.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 59 Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
1.5.3 Diseases of the Venous 1.8.3.1 Aneurysmal Disease:
Circulation . . . . . . . . . . . . . . . . . . . . . . . 59 Abdominal Aortic Aneurysm . . . . . . 89
1.5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 59 1.8.3.3 Peripheral Vascular Disease:
1.5.3.2 Chronic Venous Insufficiency . . . . . . 59 Chronic Lower Limb Ischaemia . . . . 89
1.5.3.3 Deep Vein Thrombosis . . . . . . . . . . . . 61 1.8.3.4 Peripheral Vascular Disease:
1.5.3.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . 61 Acute Limb Ischaemia . . . . . . . . . . . . . 90
References . . . . . . . . . . . . . . . . . . . . . . . . 62 1.8.3.5 Carotid Disease . . . . . . . . . . . . . . . . . . . 91

15. Contents XV
1.8.3.6 Venous Disease . . . . . . . . . . . . . . . . . . . 92 1.10 Training of the Vascular
References . . . . . . . . . . . . . . . . . . . . . . . . 93 Surgeonfor Endovascular
Procedures . . . . . . . . . . . . . . . . . . . . . 107
1.9 Peri-operative Care References . . . . . . . . . . . . . . . . . . . . . . 110
of the Vascular Patient . . . . . . . . . . . . . 95
1.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . 95 1.11 Peripheral Arterial Disease and
1.9.2 Preoperative Planning . . . . . . . . . . . . . 95 Emerging Biochemical Vascular
1.9.3 Effects of Anaesthesia . . . . . . . . . . . . . . 95 Risk Factors . . . . . . . . . . . . . . . . . . . . 111
1.9.4 Peri-operative Monitoring . . . . . . . . . 96 1.11.1 Introduction . . . . . . . . . . . . . . . . . . . . 111
1.9.4.1 Monitoring for Cardiac 1.11.2 Homocysteine (Hcy) . . . . . . . . . . . . 111
Ischaemia . . . . . . . . . . . . . . . . . . . . . . . . 96 1.11.3 C-reactive Protein (CRP) . . . . . . . . 111
1.9.4.2 Peri-operative Temperature 1.11.4 Lipoprotein (a) [Lp(a)] . . . . . . . . . . 112
Control . . . . . . . . . . . . . . . . . . . . . . . . . . 96 1.11.5 Fibrinogen . . . . . . . . . . . . . . . . . . . . . . 112
1.9.4.3 Level of Hypnotic Depth . . . . . . . . . . . 97 1.11.6 Endothelium . . . . . . . . . . . . . . . . . . . . 113
1.9.5 Prevention of Cardiac Ischaemia . . . 97 1.11.7 PAD and Other Potentially
1.9.5.1 Preoperative Revascularization . . . . . 97 Relevant Emerging Risk Factors . . 113
1.9.5.2 Good Peri-operative 1.11.7.1 Creatinine . . . . . . . . . . . . . . . . . . . . . . 113
Haemodynamic Control . . . . . . . . . . . 97 1.11.7.2 Urate . . . . . . . . . . . . . . . . . . . . . . . . . . 113
1.9.5.3 Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . 97 1.11.7.3 Microalbuminuria . . . . . . . . . . . . . . 114
1.9.5.4 Adrenergic Tone . . . . . . . . . . . . . . . . . . 97 1.11.7.4 Insulin Resistance and Metabolic
1.9.5.5 Postoperative Ischaemia Syndrome . . . . . . . . . . . . . . . . . . . . . . 114
Prevention . . . . . . . . . . . . . . . . . . . . . . . 98 1.11.7.5 Platelets, Fibrinolysis
1.9.6 Aneurysm Surgery . . . . . . . . . . . . . . . . 98 and D-Dimers . . . . . . . . . . . . . . . . . . 114
1.9.6.1 Effects of Clamping and 1.11.7.6 Other Markers of Inflammation . . 114
Declamping . . . . . . . . . . . . . . . . . . . . . . 98 1.11.8 Conclusions . . . . . . . . . . . . . . . . . . . . 114
1.9.6.2 Prevention of Spinal Cord References . . . . . . . . . . . . . . . . . . . . . 115
Ischaemia in Thoracic Aortic
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 99 1.12 Quality Control in Vascular
1.9.6.3 Autotransfusion During Surgery . . . . 99 Surgery . . . . . . . . . . . . . . . . . . . . . . . . 117
1.9.7 Heparin . . . . . . . . . . . . . . . . . . . . . . . . . . 99 1.12.1 Introduction . . . . . . . . . . . . . . . . . . . . 117
1.9.7.1 Peri-operative Heparin . . . . . . . . . . . . 99 1.12.1.1 Physical Examination . . . . . . . . . . . . 117
1.9.7.2 Prophylaxis of Deep Leg Vein 1.12.1.2 Angiography . . . . . . . . . . . . . . . . . . . . 117
Thrombosis . . . . . . . . . . . . . . . . . . . . . 100 1.12.1.3 Continuous Wave (CW)
1.9.8 Peri-operative Monitoring Doppler . . . . . . . . . . . . . . . . . . . . . . . . 117
after Arterial Reconstructions . . . . 100 1.12.1.4 Duplex and Colour Duplex Scan . . 118
1.9.9 Prophylactic Antibiotic 1.12.1.5 Intravascular Ultrasonography
Administration . . . . . . . . . . . . . . . . . 100 (IVUS) . . . . . . . . . . . . . . . . . . . . . . . . . 118
1.9.10 Postoperative Pain Treatment . . . . 100 1.12.1.6 Angioscopy . . . . . . . . . . . . . . . . . . . . . 118
1.9.11 Pulmonary Complications, 1.12.1.7 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 119
Prophylaxis and Treatment . . . . . . . 100 1.12.2 Arteries of the Abdomen . . . . . . . . 119
1.9.12 Peri-operative Care 1.12.2.1 Abdominal Aorta . . . . . . . . . . . . . . . 119
and Endovascular Surgery . . . . . . . 101 1.12.2.2 Visceral Arteries . . . . . . . . . . . . . . . . 119
1.9.13 Intensive Care Ward is Needed 1.12.2.3 Renal Arteries . . . . . . . . . . . . . . . . . . 120
Only for Selected Patients . . . . . . . . 101 1.12.3 Lower Extremity By-pass . . . . . . . . 120
1.9.14 Pre- and Postoperative Gut 1.12.3.1 Angiography . . . . . . . . . . . . . . . . . . . . 121
Function and Nutrition . . . . . . . . . . 101 1.12.3.2 Ultrasound (CW Doppler, PW
1.9.15 Discharge Planning . . . . . . . . . . . . . . 102 Doppler, Duplex, Colour Duplex) 122
1.9.16 Summary . . . . . . . . . . . . . . . . . . . . . . . 103 1.12.3.3 Angioscopy . . . . . . . . . . . . . . . . . . . . . 123
References . . . . . . . . . . . . . . . . . . . . . . 103 1.12.3.4 Flowmetry . . . . . . . . . . . . . . . . . . . . . . 124
1.12.3.5 Conclusions . . . . . . . . . . . . . . . . . . . . 124

16. XVI Contents
1.12.4 Carotid Arteries . . . . . . . . . . . . . . . . . 124 2.2.5.3 Technique of Carotid
References . . . . . . . . . . . . . . . . . . . . . . 127 Endarterectomy . . . . . . . . . . . . . . . . . 146
2.2.6 Endovascular Treatment . . . . . . . . . 149
2.2.6.1 What are the Established
Cerebrovascular Arteries Indications for Endovascular
Procedures in Extracranial
2.1 Haemodynamic Changes Carotid Disease? . . . . . . . . . . . . . . . . 149
and Other Risk Factors References . . . . . . . . . . . . . . . . . . . . . . 150
for Complications During
Carotid Procedures . . . . . . . . . . . . . . 131 2.3 Eversion Carotid
2.1.1 Cerebral Blood Flow . . . . . . . . . . . . . 131 Endarterectomy Technique . . . . . . 155
2.1.2 General Complications . . . . . . . . . . 131 2.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 155
2.1.3 Cerebral Monitoring 2.3.2 Technique . . . . . . . . . . . . . . . . . . . . . . 155
and Protection During CEA . . . . . . 132 2.3.3 Advantages . . . . . . . . . . . . . . . . . . . . . 159
2.1.4 Cerebral Embolization during 2.3.4 Disadvantages . . . . . . . . . . . . . . . . . . 159
CEA and CAS . . . . . . . . . . . . . . . . . . 133 2.3.5 Conclusion . . . . . . . . . . . . . . . . . . . . . 159
2.1.5 Adjuvant Medical Therapy . . . . . . . 133 References . . . . . . . . . . . . . . . . . . . . . . 159
2.1.6 Conclusion . . . . . . . . . . . . . . . . . . . . . 134
References . . . . . . . . . . . . . . . . . . . . . . 134 2.4 Fibromuscular Dysplasia . . . . . . . . . 161
2.4.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 161
2.2 Extracranial Carotid Artery 2.4.1.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . 161
Disease . . . . . . . . . . . . . . . . . . . . . . . . . 137 2.4.1.2 Physiology, Pathophysiology . . . . . 161
2.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 137 2.4.1.3 Organ-related Questions . . . . . . . . . 165
2.2.2 Pathogenesis of Brain Ischaemia . . 138 2.4.1.4 Principles of Clinical
2.2.3 Clinical Manifestations . . . . . . . . . . 140 Examination . . . . . . . . . . . . . . . . . . . . 165
2.2.3.1 Amaurosis fugax . . . . . . . . . . . . . . . . 140 2.4.1.5 Technical Diagnostic Procedures . . 165
2.2.3.2 Transient/Reversible Cerebral 2.4.1.6 Organ-specific Radiology . . . . . . . . 166
Ischaemia . . . . . . . . . . . . . . . . . . . . . . 140 2.4.2 Organ-related Diseases . . . . . . . . . . 166
2.2.3.3 Established Stroke . . . . . . . . . . . . . . . 140 2.4.2.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 166
2.2.3.4 Stroke in Evolution (“Waving 2.4.2.2 Definition . . . . . . . . . . . . . . . . . . . . . . 166
and Waning”) . . . . . . . . . . . . . . . . . . . 140 2.4.2.3 Epidemiology/Aetiology . . . . . . . . . 166
2.2.3.5 Global Cerebral Ischaemia . . . . . . . 140 2.4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 167
2.2.3.6 Asymptomatic Carotid Disease . . . 141 2.4.2.5 Complications . . . . . . . . . . . . . . . . . . 168
2.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 141 2.4.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 168
2.2.4.1 Arteriography . . . . . . . . . . . . . . . . . . . 141 2.4.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 168
2.2.4.2 Colour Flow Duplex Scan . . . . . . . 141 2.4.2.8 Differential Diagnosis . . . . . . . . . . . 169
2.2.4.3 High-resolution 2.4.2.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 169
Ultrasonography . . . . . . . . . . . . . . . . 143 2.4.2.10 Exemplary Surgical Procedures . . . 169
2.2.4.4 Measuring the Degree of Stenosis . 143 2.4.2.11 Special Remarks . . . . . . . . . . . . . . . . . 170
2.2.4.5 Transcranial Doppler References . . . . . . . . . . . . . . . . . . . . . . 170
Examination . . . . . . . . . . . . . . . . . . . 144
2.2.4.6 Other Flow-imaging Techniques . . 144 2.5 Aneurysms of the Extracranial
2.2.4.7 Indications for Arteriography . . . . 144 Carotid Arteries . . . . . . . . . . . . . . . . 173
2.2.4.8 Computerized Tomography 2.5.1 Definition and Historical
and Magnetic Resonance Imaging 144 Background . . . . . . . . . . . . . . . . . . . . 173
2.2.4.9 Examination of the Retina . . . . . . . 144 2.5.2 Epidemiology/Aetiology . . . . . . . . . 173
2.2.5 Selection, Treatment and Results . . 145 2.5.2.1 Atherosclerosis Aneurysms . . . . . . 173
2.2.5.1 Medical Treatment . . . . . . . . . . . . . . 145 2.5.2.2 Previous Surgery/POS
2.2.5.2 Surgical Treatment . . . . . . . . . . . . . . 145 Endarterectomy . . . . . . . . . . . . . . . . . 174

17. Contents XVII
2.5.2.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.1 Technical Failure . . . . . . . . . . . . . . . . 193
2.5.2.4 Infection . . . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.2 Contrast Encephalopathy . . . . . . . . 193
2.5.2.5 Dissections . . . . . . . . . . . . . . . . . . . . . 174 2.6.8.3 Access Site Complications . . . . . . . . 193
2.5.2.6 Other Possible Causes . . . . . . . . . . . 174 2.6.8.4 Hyperperfusion Syndrome
2.5.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 175 (Fig. 2.6.16) . . . . . . . . . . . . . . . . . . . . . 193
2.5.4 Complications . . . . . . . . . . . . . . . . . . 175 2.6.8.5 Hypotension and Bradycardia . . . 194
2.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 175 2.6.8.6 Embolic Complication . . . . . . . . . . . 194
2.5.5.1 Recommended European 2.6.8.7 Complications Involving Brain
Standard Diagnostic Steps Protection Devices . . . . . . . . . . . . . . 195
of Investigation . . . . . . . . . . . . . . . . . 175 2.6.9 Follow-up . . . . . . . . . . . . . . . . . . . . . . 195
2.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 176 2.6.10 Carotid Angioplasty and
2.5.6.1 Conservative Treatment . . . . . . . . . 176 Stenting (CAS): Present and Future 196
2.5.6.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 177 References . . . . . . . . . . . . . . . . . . . . . . 197
References . . . . . . . . . . . . . . . . . . . . . . 179
2.7 Carotid body tumour . . . . . . . . . . . . 201
2.6 Endovascular Treatment 2.7.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 201
of Carotid Stenosis . . . . . . . . . . . . . . 181 2.7.2 Definition of the Disease . . . . . . . . . 201
2.6.1 Introduction . . . . . . . . . . . . . . . . . . . . 181 2.7.3 Epidemiology/Aetiology . . . . . . . . . 201
2.6.2 Indications for Surgery 2.7.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 202
– Indications for Angioplasty . . . . . 181 2.7.5 Complications . . . . . . . . . . . . . . . . . . 202
2.6.3 Types of Stents . . . . . . . . . . . . . . . . . . 183 2.7.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 203
2.6.4 Brain Protection Devices . . . . . . . . . 184 2.7.6.1 Recommended European
2.6.4.1 Distal Occlusion Balloon Standard Diagnostic Steps
(Theron’s System, PercuSurge of Investigation . . . . . . . . . . . . . . . . . 203
GuardWire® Medtronic) 2.7.6.2 Additional Useful Diagnostic
(Fig. 2.6.5) . . . . . . . . . . . . . . . . . . . . . . 184 Procedures . . . . . . . . . . . . . . . . . . . . . 205
2.6.4.2 Filters . . . . . . . . . . . . . . . . . . . . . . . . . . 184 2.7.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 206
2.6.4.3 Proximal Occlusion System . . . . . . 186 2.7.7.1 Conservative therapy . . . . . . . . . . . . 206
2.6.5 Preoperative Evaluation . . . . . . . . . . 187 2.7.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 206
2.6.5.1 Neurological Examination . . . . . . . 188 2.7.8 Differential Diagnosis . . . . . . . . . . . 208
2.6.5.2 Special Imaging Examination . . . . 188 References . . . . . . . . . . . . . . . . . . . . . 208
2.6.5.3 Duplex Ultrasound . . . . . . . . . . . . . . 188
2.6.5.4 Digital Subtraction Angiography 2.8 Combined Treatment of
(DSA) . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Coronary Plus Other Arterial
2.6.5.5 Magnetic Resonance Pathologies: the Magnitude of
Angiography (MRA) (Fig. 2.6.10) . . 189 the Polyatherosclerotic Patient . . . 209
2.6.5.6 Brain Computed Tomography 2.8.1 Introduction . . . . . . . . . . . . . . . . . . . . 209
(CT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 2.8.2 The Magnitude of Multifocal
2.6.6 Technique . . . . . . . . . . . . . . . . . . . . . . 190 Arterial Disease . . . . . . . . . . . . . . . . . 209
2.6.6.1 Step 1: Approach to the 2.8.2.1 Material and Methods . . . . . . . . . . . 209
Common Carotid Artery Access 2.8.2.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 209
Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 2.8.3 Multifocal Occlusive
2.6.6.2 Step 2: Cannulation of the and Aneurysmal Arterial Disease . 211
Common Carotid Artery 2.8.4 Multifocal Carotid and
(Fig. 2.6.12) . . . . . . . . . . . . . . . . . . . . . 191 Coronary Occlusive Disease . . . . . 212
2.6.6.3 Step 3: Angioplasty and Stenting . . 192 2.8.4.1 Material and Methods . . . . . . . . . . . 213
2.6.6.4 Step 4: Control Angiography . . . . . 193 2.8.4.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . 214
2.6.7 Peri-operative Monitoring . . . . . . . 193 Acknowledgements . . . . . . . . . . . . . 214
2.6.8 Complications . . . . . . . . . . . . . . . . . . 193 References . . . . . . . . . . . . . . . . . . . . . . 214

18. XVIII Contents
Upper Extremity Arteries 3.2.2.2 Epidemiology/Aetiology . . . . . . . . . 240
3.2.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 240
3.1 Upper Extremity Occlusive 3.2.2.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 241
Disease . . . . . . . . . . . . . . . . . . . . . . . . . 219 3.2.3 Acrocyanosis . . . . . . . . . . . . . . . . . . . 242
3.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 219 3.2.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 242
3.1.2 Types of Upper Extremity 3.2.3.2 Epidemiology/Aetiology . . . . . . . . . 242
Occlusive Disease . . . . . . . . . . . . . . . 219 3.2.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 242
3.1.2.1 Acute and Chronic Ischaemia . . . . 219 3.2.3.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 243
3.1.2.2 Raynaud’s Phenomenon . . . . . . . . . 219 3.2.4 Livedo Reticularis . . . . . . . . . . . . . . . 243
3.1.2.3 Trophic Lesions . . . . . . . . . . . . . . . . . 220 3.2.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 243
3.1.2.4 Differential Diagnosis of Upper 3.2.4.2 Epidemiology/Aetiology . . . . . . . . . 243
Extremity Occlusive Disease . . . . . 220 3.2.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 243
3.1.3 Embolism . . . . . . . . . . . . . . . . . . . . . . 220 3.2.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 243
3.1.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 220 3.2.5 Cold Hypersensitivity . . . . . . . . . . . 243
3.1.3.2 Epidemiology/Aetiology . . . . . . . . . 220 3.2.5.1 Definition . . . . . . . . . . . . . . . . . . . . . . 243
3.1.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 220 3.2.5.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 244
3.1.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 221 3.2.5.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 244
3.1.3.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 221 3.2.6 Complex Regional Pain
3.1.4 Occlusive Arterial Disease . . . . . . . 222 Syndrome . . . . . . . . . . . . . . . . . . . . . . 245
3.1.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 222 3.2.6.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 245
3.1.4.2 Proximal Arterial Disease . . . . . . . . 222 3.2.6.2 Definition . . . . . . . . . . . . . . . . . . . . . . 245
3.1.4.3 Distal Arterial Disease . . . . . . . . . . . 226 3.2.6.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 245
3.1.5 Aneurysms . . . . . . . . . . . . . . . . . . . . . 232 3.2.6.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 245
3.1.5.1 Epidemiology/Aetiology . . . . . . . . . 232 3.2.6.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 245
3.1.5.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 232 References . . . . . . . . . . . . . . . . . . . . . . 246
3.1.5.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 232
3.1.6 Arteriovenous Fistulae . . . . . . . . . . . 232 3.3 Thoracic Outlet Syndrome . . . . . . . 247
3.1.6.1 Epidemiology/Aetiology . . . . . . . . . 232 3.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 247
3.1.6.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2 Neurogenic Thoracic Outlet
3.1.6.3 Investigations . . . . . . . . . . . . . . . . . . . 233 Compression Syndrome (N-TOCS) 247
3.1.6.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.1 Epidemiology/Aetiology . . . . . . . . . 247
3.1.7 Vascular Trauma . . . . . . . . . . . . . . . . 233 3.3.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 247
3.1.7.1 Epidemiology/Aetiology . . . . . . . . . 233 3.3.2.3 Clinical Examination . . . . . . . . . . . . 247
3.1.7.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 248
3.1.7.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 233 3.3.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 248
3.1.8 Iatrogenic Aetiologies . . . . . . . . . . . 233 3.3.3 Arterial Thoracic Outlet
3.1.9 Conclusion . . . . . . . . . . . . . . . . . . . . . 234 Compression Syndrome
References . . . . . . . . . . . . . . . . . . . . . . 234 (A-TOCS) . . . . . . . . . . . . . . . . . . . . . 251
3.3.3.1 Epidemiology/Aetiology . . . . . . . . . 251
3.2 Vasospastic Disorders 3.3.3.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 251
of the Upper Extremities . . . . . . . . . 237 3.3.3.3 Investigations/Examination . . . . . . 251
3.2.1 Raynaud’s Syndrome . . . . . . . . . . . . 237 3.3.3.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 251
3.2.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 237 3.3.4 A Case Apart: Primary
3.2.1.2 Epidemiology/Aetiology . . . . . . . . . 237 Subclavian–Axillary Vein
3.2.1.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 237 Thrombosis . . . . . . . . . . . . . . . . . . . . . 254
3.2.1.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 237 3.3.4.1 Epidemiology/Aetiology . . . . . . . . . 254
3.2.1.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 239 3.3.4.2 Primary SVT . . . . . . . . . . . . . . . . . . . 254
3.2.2 Hyperhidrosis . . . . . . . . . . . . . . . . . . . 240 3.3.5 Summary . . . . . . . . . . . . . . . . . . . . . . . 256
3.2.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 240 References . . . . . . . . . . . . . . . . . . . . . . 256

19. Contents XIX
3.4 Traumatic Injury of Upper 4.2.3.5 Localization . . . . . . . . . . . . . . . . . . . . 278
Extremity Arteries . . . . . . . . . . . . . . 257 4.2.3.6 Classification . . . . . . . . . . . . . . . . . . . 278
3.4.1 Epidemiology . . . . . . . . . . . . . . . . . . . 257 4.2.3.7 Factors Determining Extension
3.4.2 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 257 of Dissection . . . . . . . . . . . . . . . . . . . 279
3.4.2.1 Penetrating Trauma . . . . . . . . . . . . . 257 4.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 282
3.4.2.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . 257 4.2.4.1 Stanford Type A . . . . . . . . . . . . . . . . 282
3.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 257 4.2.4.2 Stanford Type B . . . . . . . . . . . . . . . . 282
3.4.3.1 Recommended European 4.2.5 Complications . . . . . . . . . . . . . . . . . . 283
Standard Diagnostic Steps 4.2.5.1 Type A . . . . . . . . . . . . . . . . . . . . . . . . . 283
of Investigation . . . . . . . . . . . . . . . . . 257 4.2.5.2 Type B . . . . . . . . . . . . . . . . . . . . . . . . . 283
3.4.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 258 4.2.6 Diagnosis/Investigation . . . . . . . . . . 285
3.4.4.1 Conservative Therapy . . . . . . . . . . . 258 4.2.6.1 Recommended European
3.4.4.2 Endovascular Therapy . . . . . . . . . . . 258 Standard Diagnostic Steps
3.4.4.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 258 of Investigation . . . . . . . . . . . . . . . . . 285
3.4.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 259 4.2.6.2 Additional Useful Diagnostic
References . . . . . . . . . . . . . . . . . . . . . . 260 Procedures . . . . . . . . . . . . . . . . . . . . . 285
4.2.6.3 Clinical Judgement . . . . . . . . . . . . . . 285
4.2.7 Prognosis of Acute or Subacute
Thoracic Aorta Aortic Dissection Without
Treatment . . . . . . . . . . . . . . . . . . . . . . 289
4.1 Thoracoabdominal Aneurysms . . . 265 4.2.8 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 289
4.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 265 4.2.8.1 Treatment of Type A Aortic
4.1.2 Epidemiology/Aetiology . . . . . . . . . 265 Dissection . . . . . . . . . . . . . . . . . . . . . . 289
4.1.3 Investigations . . . . . . . . . . . . . . . . . . . 266 4.2.8.2 Treatment of Type B Aortic
4.1.3.1 Imaging . . . . . . . . . . . . . . . . . . . . . . . . 266 Dissection . . . . . . . . . . . . . . . . . . . . . . 290
4.1.3.2 Additional Investigations . . . . . . . . 266 References . . . . . . . . . . . . . . . . . . . . . . 296
4.1.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 267
4.1.4.1 Operative Repair . . . . . . . . . . . . . . . . 267 4.3 Trauma of the Thoracic Aorta . . . . 299
4.1.4.2 Open Surgery: Operative 4.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 299
Technique . . . . . . . . . . . . . . . . . . . . . . 267 4.3.2 Epidemiology . . . . . . . . . . . . . . . . . . . 299
4.1.4.3 Open Surgery: Adjuvant 4.3.2.1 Automobile-related Incidences . . . 299
Techniques . . . . . . . . . . . . . . . . . . . . . 267 4.3.2.2 Blunt Thoracic Trauma . . . . . . . . . . 299
4.1.5 Endovascular Intervention . . . . . . . 269 4.3.2.3 Outcome . . . . . . . . . . . . . . . . . . . . . . . 300
4.1.5.1 Visceral Hybrid Procedure . . . . . . . 269 4.3.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 300
4.1.6 Outcome . . . . . . . . . . . . . . . . . . . . . . . 271 4.3.3.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . 300
4.1.7 Summary and Conclusions . . . . . . . 272 4.3.3.2 Mechanism of Pathology . . . . . . . . . 301
References . . . . . . . . . . . . . . . . . . . . . . 273 4.3.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 301
4.3.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 302
4.2 Aortic Dissection . . . . . . . . . . . . . . . . 277 4.3.5.1 Recommended European
4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 277 Standard Diagnostic Steps
4.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . 277 of Investigation . . . . . . . . . . . . . . . . . 302
4.2.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 306
4.2.3.1 Association with Atherosclerotic 4.3.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 306
Disease . . . . . . . . . . . . . . . . . . . . . . . . . 277 4.3.6.2 Endovascular Approach . . . . . . . . . 309
4.2.3.2 Association with Genetic References . . . . . . . . . . . . . . . . . . . . . . 312
Disease/Congenital
Malformations . . . . . . . . . . . . . . . . . . 277
4.2.3.3 Association with Trauma . . . . . . . . 277
4.2.3.4 Other Associations . . . . . . . . . . . . . . 277

20. XX Contents
Abdominal Aorta and Iliac Arteries 5.3.4.2 Infection . . . . . . . . . . . . . . . . . . . . . . . 333
5.3.4.3 Autoimmune Disease . . . . . . . . . . . . 333
5.1 Abdominal Aortic Aneurysm 5.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 333
(AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 317 5.3.5.1 Literature . . . . . . . . . . . . . . . . . . . . . . . 334
5.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 317 5.3.5.2 Rupture . . . . . . . . . . . . . . . . . . . . . . . . 334
5.1.2 Definition . . . . . . . . . . . . . . . . . . . . . . 317 5.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 334
5.1.3 Epidemiology/Aetiology . . . . . . . . . 317 5.3.6.1 Recommended European
5.1.3.1 Risk Factors . . . . . . . . . . . . . . . . . . . . 318 Standard Diagnostic Steps
5.1.3.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . 318 of Investigation . . . . . . . . . . . . . . . . . 335
5.1.3.3 Incidence of AAA Rupture . . . . . . . 319 5.3.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 336
5.1.3.4 Disease Progression . . . . . . . . . . . . . 319 5.3.7.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 336
5.1.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 320 5.3.7.2 Endovascular Treatment . . . . . . . . . 338
5.1.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 320 References . . . . . . . . . . . . . . . . . . . . . . 341
5.1.4.1 Expanding Aneurysm . . . . . . . . . . . 320
5.1.4.2 Inflammatory AAA . . . . . . . . . . . . . . 320 5.4 Technically Challenging Cases
5.1.4.3 Rupture . . . . . . . . . . . . . . . . . . . . . . . . 320 for Endovascular Repair
5.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 321 of Aortic Aneurysms . . . . . . . . . . . . 343
5.1.5.1 Recommended European 5.4.1 Introduction . . . . . . . . . . . . . . . . . . . . 343
Standard Diagnostic Steps 5.4.2 Universally Challenging
of Investigation . . . . . . . . . . . . . . . . . 321 Situations . . . . . . . . . . . . . . . . . . . . . . 343
5.1.5.2 Aspects on Screening . . . . . . . . . . . . 321 5.4.2.1 Vascular Access Morphology . . . . . 343
5.1.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 322 5.4.2.2 Aortic Aneurysm Configuration . . 343
5.1.6.1 Open Surgery . . . . . . . . . . . . . . . . . . . 322 5.4.3 Special Challenging Situations . . . . 347
5.1.6.2 Endovascular Aortic Repair 5.4.3.1 The Case of Aortic Arch
(EVAR) . . . . . . . . . . . . . . . . . . . . . . . . 322 Aneurysm . . . . . . . . . . . . . . . . . . . . . . 347
5.1.6.3 Rupture and Reconstruction . . . . . 322 5.4.3.2 The Case of Aortic Dissection . . . . 347
5.1.6.4 Outcome . . . . . . . . . . . . . . . . . . . . . . . 323 5.4.3.3 The Case of Aortic Bronchial
5.1.7 Possible Complications and Enteric Fistula . . . . . . . . . . . . . . 349
of Surgery . . . . . . . . . . . . . . . . . . . . . . 323 5.4.3.4 Other Challenging Cases
5.1.8 Practical Recommendations . . . . . . 323 for EVAR . . . . . . . . . . . . . . . . . . . . . . . 350
References . . . . . . . . . . . . . . . . . . . . . . 323 5.4.4 Conclusion . . . . . . . . . . . . . . . . . . . . . 350
References . . . . . . . . . . . . . . . . . . . . . . 351
5.2 Treatment Options for
Abdominal Aortic Aneurysm 5.5 Aortoiliac Occlusive Disease . . . . . 355
(AAA) . . . . . . . . . . . . . . . . . . . . . . . . . 325 5.5.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 355
5.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 325 5.5.2 Synonyms . . . . . . . . . . . . . . . . . . . . . . 355
5.2.2 Open Repair . . . . . . . . . . . . . . . . . . . . 325 5.5.3 Definition . . . . . . . . . . . . . . . . . . . . . . 355
5.2.2.1 Complications . . . . . . . . . . . . . . . . . . 327 5.5.3.1 Morphological Features
5.2.3 Endovascular Repair . . . . . . . . . . . . 327 in the Chronic Forms . . . . . . . . . . . . 356
5.2.3.1 Complications . . . . . . . . . . . . . . . . . . 328 5.5.4 Epidemiology . . . . . . . . . . . . . . . . . . . 357
References . . . . . . . . . . . . . . . . . . . . . . 329 5.5.5 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 357
5.5.6 Symptoms . . . . . . . . . . . . . . . . . . . . . . 358
5.3 Inflammatory Aneurysms 5.5.6.1 Chronic AIOD . . . . . . . . . . . . . . . . . . 358
of the Abdominal Aorta . . . . . . . . . 331 5.5.6.2 Acute AIOD . . . . . . . . . . . . . . . . . . . . 359
5.3.1 Introduction . . . . . . . . . . . . . . . . . . . . 331 5.5.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 359
5.3.2 Definition . . . . . . . . . . . . . . . . . . . . . . 331 5.5.7.1 Recommended European
5.3.3 Epidemiology . . . . . . . . . . . . . . . . . . . 332 Standard . . . . . . . . . . . . . . . . . . . . . . . 359
5.3.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 333 5.5.7.2 Additional/Useful Diagnostic
5.3.4.1 Extension of Inflammation . . . . . . . 333 Procedures . . . . . . . . . . . . . . . . . . . . . 360

21. Contents XXI
5.5.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 360 5.6.3 Totally Laparoscopic Operative
5.5.8.1 Conservative Treatment . . . . . . . . . 360 Procedures . . . . . . . . . . . . . . . . . . . . . 377
5.5.8.2 Endovascular and Surgical 5.6.3.1 Retrocolic or Prerenal
Treatment . . . . . . . . . . . . . . . . . . . . . . 361 Transperitoneal Procedure as
5.5.9 Differential Diagnosis . . . . . . . . . . . 363 Described by Coggia [8, 11] . . . . . . 377
5.5.9.1 In the Case of Chronic AIOD . . . . 363 5.6.3.2 Combined Transperitoneal
5.5.9.2 In the Case of Acute AIOD . . . . . . . 363 and Retroperitoneal Procedures . . 379
5.5.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 363 5.6.3.3 Retroperitoneal Operation . . . . . . . 380
5.5.11 Surgical and Endovascular 5.6.3.4 Direct Transperitoneal
Principle . . . . . . . . . . . . . . . . . . . . . . . 364 Procedure [7] . . . . . . . . . . . . . . . . . . . 380
5.5.11.1 Aortoiliac Angioplasty and 5.6.4 Instrumentation . . . . . . . . . . . . . . . . . 381
Stenting . . . . . . . . . . . . . . . . . . . . . . . . 364 5.6.4.1 Standard Laparoscopic
5.5.11.1 Unilateral and Bilateral Instruments . . . . . . . . . . . . . . . . . . . . 381
Aortofemoral By-pass . . . . . . . . . . . 365 5.6.4.2 Specific Laparoscopic
5.5.11.2 Unilateral or Bilateral Aortoiliac Instruments for Vascular
By-pass . . . . . . . . . . . . . . . . . . . . . . . . . 366 Laparoscopy . . . . . . . . . . . . . . . . . . . . 381
5.5.11.3 Aortic Exclusion and Bilateral 5.6.5 Complications . . . . . . . . . . . . . . . . . . 382
Aortoiliac or Bilateral 5.6.5.1 Intraoperative Complications . . . . 382
Aortofemoral Prosthetic 5.6.5.2 Early Postoperative
Reconstruction . . . . . . . . . . . . . . . . . 367 Complications . . . . . . . . . . . . . . . . . . 382
5.5.11.4 Unilateral or Bilateral 5.6.6 Current Indications and Results . . 383
Thoracoiliofemoral By-pass . . . . . . 367 5.6.7 Conclusions . . . . . . . . . . . . . . . . . . . . 384
5.5.11.5 Aortoiliac Endarterectomy . . . . . . . 368 References . . . . . . . . . . . . . . . . . . . . . . 384
5.5.11.6 Iliofemoral By-pass . . . . . . . . . . . . . . 368
5.5.11.7 Femoro-femoral Cross-over 5.7 Aortouniiliac Endoprosthesis
By-pass . . . . . . . . . . . . . . . . . . . . . . . . . 368 and Femoro-femoral Crossover
5.5.11.8 Unilateral or Bilateral for AAA Repair . . . . . . . . . . . . . . . . . 387
Axillofemoral By-pass . . . . . . . . . . . 369 5.7.1 Introduction . . . . . . . . . . . . . . . . . . . . 387
5.5.11.9 Retrograde Femoral 5.7.2 Definition . . . . . . . . . . . . . . . . . . . . . . 387
Embolectomy . . . . . . . . . . . . . . . . . . . 369 5.7.3 Indications . . . . . . . . . . . . . . . . . . . . . 387
5.5.11.10 New Surgical Trends . . . . . . . . . . . . . 370 5.7.4 Contraindications . . . . . . . . . . . . . . . 388
5.5.11.11 Aortobifemoral Video-assisted 5.7.5 Preoperative Management . . . . . . . 388
By-pass with Hand-Port System . . 371 5.7.6 Procedure . . . . . . . . . . . . . . . . . . . . . . 388
5.5.11.12 Aortobifemoral Totally 5.7.7 Results and Complications . . . . . . . 389
Laparoscopic By-pass 5.7.8 Patency of the Femoro-femoral
with Coggia’s Technique . . . . . . . . . 372 Crossover By-pass . . . . . . . . . . . . . . 390
References . . . . . . . . . . . . . . . . . . . . . . 373 5.7.9 Local Wound Complications,
Graft Infection and Morbidity . . . 391
5.6 Aortobifemoral By-pass: 5.7.10 Conclusion . . . . . . . . . . . . . . . . . . . . . 395
Laparoscopy-Assisted and References . . . . . . . . . . . . . . . . . . . . . . 395
Totally Laparoscopic Operative
Procedures . . . . . . . . . . . . . . . . . . . . . 375
5.6.1 Introduction . . . . . . . . . . . . . . . . . . . . 375 Visceral Arteries
5.6.2 Operative Procedures . . . . . . . . . . . . 375
5.6.2.1 Laparoscopy-Assisted Operative 6.1 Occlusive Disease of the Coeliac
Procedures with Vascular and Superior Mesenteric Arteries . 401
Suturing by the Minimally 6.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 401
Invasive Route . . . . . . . . . . . . . . . . . . 375 6.1.2 Epidemiology . . . . . . . . . . . . . . . . . . . 401
6.1.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 401

22. XXII Contents
6.1.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 402 6.3.5.1 Thrombosis . . . . . . . . . . . . . . . . . . . . . 422
6.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 402 6.3.5.2 Embolism . . . . . . . . . . . . . . . . . . . . . . 422
6.1.5.1 Recommended European References . . . . . . . . . . . . . . . . . . . . . . 423
Standard Diagnostic Steps
of Investigation . . . . . . . . . . . . . . . . . 402
6.1.5.2 Additional Useful Diagnostic Lower Extremity Arteries
Procedures . . . . . . . . . . . . . . . . . . . . . 403
6.1.6 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 403 7.1 Lower Limb Arterial
6.1.6.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 404 Recanalization . . . . . . . . . . . . . . . . . . 427
6.1.6.2 Angioplasty . . . . . . . . . . . . . . . . . . . . . 406 7.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 427
6.1.7 Conclusion . . . . . . . . . . . . . . . . . . . . . 408 7.1.2 Problems and Questions . . . . . . . . . 427
References . . . . . . . . . . . . . . . . . . . . . . 408 7.1.2.1 Solved Problems . . . . . . . . . . . . . . . . 428
7.1.2.2 Unsolved Problems . . . . . . . . . . . . . . 428
6.2 Visceral Artery Aneurysms . . . . . . 411 7.1.2.3 Permanent Problems . . . . . . . . . . . . 430
6.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 411 7.1.2.4 Arising Questions . . . . . . . . . . . . . . . 430
6.2.2 Epidemiology . . . . . . . . . . . . . . . . . . . 411 7.1.3 Conclusions . . . . . . . . . . . . . . . . . . . . 432
6.2.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 411 References . . . . . . . . . . . . . . . . . . . . . 433
6.2.4 Symptoms . . . . . . . . . . . . . . . . . . . . . . 412
6.2.5 Complications . . . . . . . . . . . . . . . . . . 412 7.2 Femorodistal By-pass Surgery . . . . 437
6.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.1 Introduction . . . . . . . . . . . . . . . . . . . . 437
6.2.7 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.2 General Considerations . . . . . . . . . . 437
6.2.7.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 413 7.2.3 Operative Indications . . . . . . . . . . . . 438
6.2.7.2 Endovascular Therapy . . . . . . . . . . . 414 7.2.4 Technical Considerations . . . . . . . . 438
6.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 414 7.2.4.1 Proximal Anastomotic Site . . . . . . . 438
References . . . . . . . . . . . . . . . . . . . . . . 415 7.2.4.2 Graft Material . . . . . . . . . . . . . . . . . . . 439
7.2.4.3 Distal Anastomotic Site
6.3 Acute Ischaemia of the Visceral (Fig. 7.2.3) . . . . . . . . . . . . . . . . . . . . . . 441
Arteries . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.5 Special Considerations . . . . . . . . . . . 442
6.3.1 Acute Intestinal Ischaemia . . . . . . . 417 7.2.6 Graft Surveillance . . . . . . . . . . . . . . . 443
6.3.1.1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . 417 7.2.7 Results . . . . . . . . . . . . . . . . . . . . . . . . . 443
6.3.2 Acute Thrombotic or Embolic 7.2.7.1 Survival . . . . . . . . . . . . . . . . . . . . . . . . 443
Arterial Occlusion . . . . . . . . . . . . . . 417 7.2.7.2 Graft Patency and Limb Salvage . . 443
6.3.2.1 Epidemiology/Aetiology . . . . . . . . . 417 7.2.7.3 Quality of Life . . . . . . . . . . . . . . . . . . 445
6.3.2.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 417 References . . . . . . . . . . . . . . . . . . . . . . 445
6.3.2.3 Complications . . . . . . . . . . . . . . . . . . 418
6.3.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 418 7.3 Acute Ischaemia of the Lower
6.3.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 419 Extremities . . . . . . . . . . . . . . . . . . . . . 449
6.3.3 Mesenteric Venous Thrombosis . . 419 7.3.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . 449
6.3.3.1 Epidemiology/Aetiology . . . . . . . . . 419 7.3.2 Definition . . . . . . . . . . . . . . . . . . . . . . 449
6.3.3.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 420 7.3.3 Epidemiology . . . . . . . . . . . . . . . . . . . 449
6.3.3.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 420 7.3.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 449
6.3.3.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 420 7.3.4.1 Embolism . . . . . . . . . . . . . . . . . . . . . . 449
6.3.4 Intestinal Ischaemia 7.3.4.2 Thrombosis . . . . . . . . . . . . . . . . . . . . . 450
after Aortoiliac Surgery . . . . . . . . . . 420 7.3.4.3 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 451
6.3.4.1 Epidemiology/Aetiology . . . . . . . . . 420 7.3.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 451
6.3.4.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.1 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
6.3.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.2 Paraesthesia . . . . . . . . . . . . . . . . . . . . 451
6.3.4.4 Treatment . . . . . . . . . . . . . . . . . . . . . . 421 7.3.5.3 Paralysis . . . . . . . . . . . . . . . . . . . . . . . . 451
6.3.5 Acute Renal Ischaemia . . . . . . . . . . . 422 7.3.5.4 Pallor . . . . . . . . . . . . . . . . . . . . . . . . . . 452

23. Contents XXIII
7.3.5.5 Pulselessness . . . . . . . . . . . . . . . . . . . . 452 7.5 Buerger’s Disease of the Lower
7.3.6 Complications . . . . . . . . . . . . . . . . . . 452 Extremities . . . . . . . . . . . . . . . . . . . . . 471
7.3.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 452 7.5.1 Synonym . . . . . . . . . . . . . . . . . . . . . . . 471
7.3.7.1 Recommended European 7.5.2 Definition . . . . . . . . . . . . . . . . . . . . . . 471
Standard Diagnostic Steps 7.5.3 Epidemiology . . . . . . . . . . . . . . . . . . . 471
of Investigation . . . . . . . . . . . . . . . . . 452 7.5.4 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 471
7.3.7.2 Additional Useful Diagnostic 7.5.5 Symptoms . . . . . . . . . . . . . . . . . . . . . . 472
Procedures . . . . . . . . . . . . . . . . . . . . . 453 7.5.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 473
7.3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . 453 7.5.6.1 Recommended European
7.3.8.1 Conservative Treatment . . . . . . . . . 453 Standard Diagnostic Steps
7.3.8.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 453 of Investigation . . . . . . . . . . . . . . . . . 473
7.3.8.3 Thrombolytic Therapy . . . . . . . . . . . 455 7.5.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 476
7.3.9 Differential Diagnosis . . . . . . . . . . . 457 7.5.7.1 Conservative Treatment . . . . . . . . . 476
7.3.10 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 457 7.5.7.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 476
References . . . . . . . . . . . . . . . . . . . . . . 457 7.5.7.3 Differential Diagnosis . . . . . . . . . . . 477
7.5.7.4 Prognosis . . . . . . . . . . . . . . . . . . . . . . . 477
7.4 Lower Extremity Aneurysms . . . . . 459 References . . . . . . . . . . . . . . . . . . . . . . 477
7.4.1 Basic Concepts . . . . . . . . . . . . . . . . . . 459
7.4.2 Popliteal Aneurysms (PA) . . . . . . . . 459 7.6 Popliteal Artery Entrapment
7.4.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . 460 and Popliteal Adventitial Cystic
7.4.2.2 Epidemiology/Aetiology . . . . . . . . . 460 Disease . . . . . . . . . . . . . . . . . . . . . . . . . 479
7.4.2.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 460 7.6.1 Definition . . . . . . . . . . . . . . . . . . . . . . 479
7.4.2.4 Complications . . . . . . . . . . . . . . . . . . 460 7.6.2 Epidemiology/Aetiology . . . . . . . . . 479
7.4.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 460 7.6.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 479
7.4.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . 461 7.6.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 480
7.4.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . 462 7.6.4.1 Recommended European
7.4.3 Aneurysms of the Common Standard Diagnostic Steps
Femoral Artery . . . . . . . . . . . . . . . . . 462 of Investigation . . . . . . . . . . . . . . . . . 480
7.4.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 462 7.6.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 481
7.4.3.2 Epidemiology/Aetiology . . . . . . . . . 462 7.6.5.1 Recommended European
7.4.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 463 Standard Surgical Procedures . . . . 481
7.4.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 464 7.6.6 Special Remarks . . . . . . . . . . . . . . . . . 483
7.4.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 464 References . . . . . . . . . . . . . . . . . . . . . . 484
7.4.3.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 466
7.4.4 Aneurysms of the Superficial 7.7 Vascular Trauma of the Lower
Femoral Artery . . . . . . . . . . . . . . . . . 466 Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
7.4.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 466 7.7.1 The Problem . . . . . . . . . . . . . . . . . . . . 485
7.4.4.2 Epidemiology/Aetiology . . . . . . . . . 467 7.7.1.1 Encountering Vascular Injury . . . . 486
7.4.4.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 467 7.7.1.2 How Can Ischaemia of the
7.4.4.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 467 Lower Limb be Detected
7.4.4.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 467 or Ruled Out Reliably? . . . . . . . . . . . 486
7.4.4.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . 467 7.7.2 Mechanisms of Injury . . . . . . . . . . . 488
7.4.5 Aneurysms of the Distal 7.7.2.1 Sharp Injury . . . . . . . . . . . . . . . . . . . . 488
Branches . . . . . . . . . . . . . . . . . . . . . . . 468 7.7.2.2 Blunt injury . . . . . . . . . . . . . . . . . . . . . 488
7.4.5.1 Epidemiology/Aetiology . . . . . . . . . 468 7.7.2.3 Iatrogenic . . . . . . . . . . . . . . . . . . . . . . 490
7.4.5.2 Clinical Symptoms . . . . . . . . . . . . . . 468 7.7.3 Consequences of Arterial Injury
7.4.5.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . 468 of the Lower Limb . . . . . . . . . . . . . . 493
7.4.5.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . 468 7.7.3.1 Compartment Syndrome . . . . . . . . 493
References . . . . . . . . . . . . . . . . . . . . . 468

24. XXIV Contents
7.7.3.2 False Aneurysms and Arterio- 9.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 525
Venous Fistulas . . . . . . . . . . . . . . . . . 494 9.1.1.1 Scope of the Problem . . . . . . . . . . . . 525
7.7.4 The Management of Vascular 9.1.2 Incidence and Morbidity
Trauma (With Special Reference of Amputation . . . . . . . . . . . . . . . . . . 525
to the Knee Joint) . . . . . . . . . . . . . . . 494 9.1.3 Classification and Indications . . . . 526
7.7.5 Bulleted Summary . . . . . . . . . . . . . . 497 9.1.3.1 Emergency Amputation . . . . . . . . . 526
References . . . . . . . . . . . . . . . . . . . . . . 497 9.1.3.2 Elective Amputations . . . . . . . . . . . . 526
9.1.4 Determination of Amputation
Level . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Diabetic Foot 9.1.4.1 Transcutaneous Oxygen Tension
(PtCO2) Measurement . . . . . . . . . . . 528
8.1 Diabetic Foot . . . . . . . . . . . . . . . . . . . 501 9.1.4.2 Clearance of [133Xe] . . . . . . . . . . . . . 528
8.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . 501 9.1.5 Preoperative Management . . . . . . . 528
8.1.2 Epidemiology . . . . . . . . . . . . . . . . . . . 501 9.1.6 Surgical Techniques of
8.1.2.1 Foot Ulcers . . . . . . . . . . . . . . . . . . . . . 501 Amputation . . . . . . . . . . . . . . . . . . . . 528
8.1.2.2 Amputation . . . . . . . . . . . . . . . . . . . . . 501 9.1.6.1 Toe Amputation . . . . . . . . . . . . . . . . . 528
8.1.2.3 Social and Economic Costs . . . . . . . 502 9.1.6.2 Ray Amputation . . . . . . . . . . . . . . . . 529
8.1.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 503 9.1.6.3 Transmetatarsal Amputation . . . . . 530
8.1.3.1 Pathogenesis of the Neuropathic 9.1.6.4 Syme’s Amputation
Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 (Ankle Disarticulation) . . . . . . . . . . 531
8.1.3.2 Pathogenesis of the Ischaemic 9.1.6.5 Below-knee Amputation . . . . . . . . . 532
Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . 505 9.1.6.6 Above-knee Amputation . . . . . . . . . 533
8.1.4 Complications: Neuro- 9.1.6.7 Amputation of the Upper
Osteoarthropathy . . . . . . . . . . . . . . . 506 Extremity . . . . . . . . . . . . . . . . . . . . . . 534
8.1.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . 506 9.1.7 Postoperative Considerations
8.1.4.2 Epidemiology . . . . . . . . . . . . . . . . . . . 506 and Rehabilitation . . . . . . . . . . . . . . . 534
8.1.4.3 Aetiology . . . . . . . . . . . . . . . . . . . . . . . 507 9.1.8 Complications . . . . . . . . . . . . . . . . . . 535
8.1.4.4 Symptoms/Investigations/ References . . . . . . . . . . . . . . . . . . . . . . 535
Diagnosis/Treatment . . . . . . . . . . . . 507
8.1.5 Diagnosis/Investigations . . . . . . . . . 507
8.1.5.1 Clinical Examination . . . . . . . . . . . . 507 Venous Diseases
8.1.5.2 Circulation . . . . . . . . . . . . . . . . . . . . . 508
8.1.5.3 Paraclinical Evaluation . . . . . . . . . . 509 10.1 Chronic Venous Insufficiency . . . . 539
8.1.5.4 Classification Systems . . . . . . . . . . . 509 10.1.1 Introduction . . . . . . . . . . . . . . . . . . . . 539
8.1.6 Differential Diagnosis . . . . . . . . . . . 509 10.1.2 Functional Anatomy and
8.1.7 Infections . . . . . . . . . . . . . . . . . . . . . . . 510 Physiology of the Venous System . . 539
8.1.7.1 Introduction . . . . . . . . . . . . . . . . . . . . 510 10.1.2.1 Superficial Veins . . . . . . . . . . . . . . . . 539
8.1.7.2 Pathophysiology . . . . . . . . . . . . . . . . 511 10.1.2.2 Deep Veins . . . . . . . . . . . . . . . . . . . . . 539
8.1.7.3 Microbiology . . . . . . . . . . . . . . . . . . . 512 10.1.2.3 Perforating Veins . . . . . . . . . . . . . . . . 539
8.1.7.4 Clinical Presentation . . . . . . . . . . . . 512 10.1.3 Chronic Venous Insufficiency . . . . 539
8.1.7.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 513 10.1.3.1 Definition . . . . . . . . . . . . . . . . . . . . . . 539
8.1.7.6 Severity Classification . . . . . . . . . . . 514 10.1.3.2 Epidemiology/Aetiology . . . . . . . . . 540
8.1.7.7 Treatment . . . . . . . . . . . . . . . . . . . . . . 515 10.1.3.3 Symptoms . . . . . . . . . . . . . . . . . . . . . . 541
8.1.8 Treatment of the Diabetic Ulcer . . 517 10.1.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 543
References . . . . . . . . . . . . . . . . . . . . . . 518 10.1.3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . 545
10.1.3.6 Conclusion . . . . . . . . . . . . . . . . . . . . . 549
References . . . . . . . . . . . . . . . . . . . . . . 549
Amputations
10.2 Deep Venous Thrombosis . . . . . . . . 551
9.1 Amputation of Extremities . . . . . . . 525 10.2.1 Epidemiology/Aetiology . . . . . . . . . 551