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• Specialty Resident, Section of Infectious Diseases, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois

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Injuries to the chest however require the surgeon to use their judgment and decide whether the injury involves the proximal left subclavian artery or not prehypertension in pregnancy 1 mg cardura purchase with mastercard. This is usually evident either by the trajectory of the missile or the presence of a hematoma in the left supraclavicular area blood pressure chart log template cardura 1 mg generic. Anatomically blood pressure 1 4 mg cardura with visa, the left subclavian artery originates from the distal aortic arch and descends in the posterior mediastinum heart attack toni braxton 4 mg cardura order mastercard. This makes vascular control of the proximal left subclavian very difficult through a median sternotomy blood pressure zones order cardura 4 mg amex. Therefore, if the surgeon feels that proximal control of the left subclavian is necessary, a left anterior thoracotomy through the third intercostal space is needed. Otherwise, a median sternotomy is the surgical approach of choice for injuries of the heart, ascending aorta, transverse aortic arch, the main pulmonary artery, innominate vein and intrathoracic vena cava. For injuries to the great vessels, a median sternotomy can be used with the appropriate cervical extension incision. At the ends of the sternum, the dissection is performed bluntly exposing the sternal notch and the subxiphoid area. The anesthesiologist is asked to hold ventilation, and the sternum is divided using a sternal saw. The surgeon should look for a hematoma obscuring the great vessels in the superior mediastinum. The hematoma should be explored in an attempt to identify the left innominate vein. This left innominate vein is a key landmark in the identification Surgical management of vascular trauma 757 to these vessels can usually be achieved at their takeoff from the aortic arch using a vascular clamp. This incision may be combined with a left or right supraclavicular incision for distal vascular control and facilitating arterial repair. With the patient in a supine position, an incision is made in the third interspace of the anterior surface of the left chest. The intercostal musculature is divided on the cephalad aspect of the rib to avoid injury to the intercostal neurovascular bundle. After entering the left chest, a Finochietto retractor is inserted between the ribs to improve exposure. The left lung is then retracted inferiorly and the surgeon should focus his attention medially and cephalad to identify the aortic arch. With a combination of sharp and blunt dissection, the aortic arch and the left subclavian origin are exposed. Proximal control of the left subclavian is achieved using a straight vascular clamp. The surgeon should attempt to identify and protect the vagus nerve as it crosses the aortic arch proximal to the take-off of the left subclavian. Once proximal control is obtained, attention is then turned to the supraclavicular region and the subclavian artery is then exposed to obtain distal control. If visualization is obscured due to hematoma, the surgeon may open the pericardium in order to find the aortic root. By tracing the aorta as it ascends from the heart, one can identify the great vessels safely. The surgeon should also think twice about using this exposure if a large hematoma exists as exposure is the key to avoiding collateral injury. If there is significant hematoma in this area, obtaining distal control of the subclavian using an infraclavicular incision more laterally may be more appropriate. To obtain supraclavicular control of the injured subclavian injury, an incision is made one fingerbreadth above the clavicle. The incision is carried down to the level of the platysma and it is divided using electrocautery. The scalene fat pad is identified and divided along its inferior and lateral margins. After retracting the scalene fat pad medially, the surgeon should attempt to identify the phrenic nerve as it crosses this region from lateral to medial on the anterior surface of the anterior scalene muscle. Once identified, it is retracted laterally by a vessel loop being cautious not to subject it to undo traction. The anterior scalene muscle is identified and divided from its insertion onto the first rib. The surgeon may need to remove a segment of this muscle to improve exposure of the underlying subclavian artery. Caution should also be used not to put undo traction on the brachial plexus where the roots exit the neck and run laterally to form the cords and innervate the arm. Most branches of the subclavian artery can be ligated with the exception of the vertebral artery. This artery should lie at the most medial and cephalad portion of the subclavian artery adjacent from the internal mammary artery. Once the subclavian artery is exposed, the surgeon can consider various methods of repair including lateral suture, ligation and bypass, interposition graft, patch angioplasty or subclavian transposition. The surgeon must consider the extent of injury, the overall status of the patient and the need or availability of conduits to perform the operation. In general there is no difference in long-term patency rate in the subclavian position whether vein or prosthetic is used. The subclavian artery stump is oversewn using a double suture technique both over and over and vertical mattress. Attention is turned to the exposed common carotid artery taking care to avoid injury to the vagus nerve. No cerebral protection is normally used when operating on the common carotid arteries. After obtaining proximal and distal control, an incision is made in the lateral side of the common carotid and enlarged using a 3­4 mm arterial punch. The subclavian artery is then turned up to and an end-to-side anastomosis is performed using a running 6-0 Prolene suture. This exposure has been reported to be associated with minimal blood loss and permits direct repair of complex injuries of the subclavian artery and veins. The dissection is carried down to the level of the periosteum using electrocautery. A Gigli saw or equivalent is used to transect the clavicle medially 760 Thoracic outlet and neck trauma over the lateral aspect of the deltopectoral groove. The fibres of the pectoralis major are split and the dissection is carried down to the level of the axillary artery. Arterial control can be obtained at this level to provide distal control of subclavian artery injuries or proximal control of vascular injuries more lateral in the arm. The insertion of the pectoralis major and minor can be preserved or divided to provide more exposure as needed. The surgeon should exercise caution to preserve the adjacent axillary nerve and vein. Special problems are encountered in these patients when there is a vascular injury and a neurological deficit; there may also be wounds of the pharynx, esophagus, trachea and major nerves. The neurological deficit associated with some of these injuries presents a unique and often perplexing problem. Injuries of vessels in the thoracic outlet, at the base of the neck, present major problems regarding surgical exposure, because it may be necessary to open the chest in order to obtain proximal control of the great vessels arising from the arch of the aorta. There are a number of vital structures in this area, and the danger of combined injuries of large arteries and veins is apparent. Subclavian artery/innominate and venous injury Subclavian and innominate vascular injuries can present with signs of injury in the thorax, thoracic outlet, cervical or upper extremity. The innominate and right subclavian artery injuries are best exposed through a median sternotomy with a right cervical extension incision if needed. Blunt injuries classically involve the proximal innominate artery, and proximal control needs to be obtained at the level of the transverse aortic arch. Simple penetrating injuries to the innominate artery can be closed with running 4-0 polypropylene, but most injuries will require an ascending aorta to distal innominate artery bypass preformed prior to opening and exploring the hematoma and area of injury. This may be more expedient and less morbid than attempting to remove the entire clavicle at the sternum. The underlying scalenus anticus muscle is identified and divided as it inserts on the first rib. An incision is made about 1 cm inferior to the clavicle Carotid injuries 761 the left subclavian artery is best approached through a combined anterolateral thoracotomy with a separate supraclavicular incision. The repair of this vessel usually requires a lateral arteriorrhaphy or graft interposition fashioned in an end-to-side manor as a standard end-to-end anastomosis cannot usually be performed. Of note, the subclavian artery is easy to injure, so care should be taken when handling and dissecting this vessel to avoid further blood loss. A significant number of these patients have other injuries, such as closed-head trauma, which can especially distort the diagnostic picture. Such combined problems are particularly confusing when the indications for surgery are being considered ­ a precise neurological evaluation is mandatory before an operation is begun. In such a situation, technical problems encountered during surgery could conceivably produce additional brain damage, although in the reported experience, this has been rare. Until a neurological problem appears in these patients, there may be little evidence of carotid artery injury. If such a lesion is untreated, it is likely to progress to complete occlusion, sometimes with extension of the clot into the cerebral arteries, producing a massive stroke. Those signs and symptoms that suggest arterial injury of vessels in the extremities apply equally to the neck, but unfortunately the cervical arteries are not directly accessible for examination of pulses, especially in patients with blunt trauma. Jernigan and Gardner17 have described features suggesting that the patient has sustained blunt trauma to the carotid artery. There may be very few signs of injury in these people, because less than half of the patients will have superficial evidence of blunt trauma. Unless these patients present with neurological symptoms, blunt trauma to the carotid artery may not be apparent for several hours or much longer in some cases. Preoperative arteriograms are needed in these situations to expose such injuries, and arteriography should be used liberally in patients who have blunt or penetrating trauma to the neck and thoracic outlet. An alternate technique for proximal carotid exposure and control has been described using a neck incision and placement of a Satinsky clamp in the superior mediastinum;40 however, we favour a median sternotomy as it provide maximal exposure and control. Uncontrollable hemorrhage will continue into the thorax until exposure is attained as most of the proximal vessels are noncompressible. Alternatively, if the vessel can be visualized from a cervical approach but is not secured with a vascular clamp, a compliant balloon can be passed retrograde for temporary proximal control. Once the vessel is properly exposed, the balloon can be replaced with the appropriate vascular clamp. Once initial exposure is obtained, local manual pressure provides adequate hemostasis as more formal proximal and distal control is attained. The complete removal of thrombus in these situations is often difficult, and leaving behind residual clots may predispose to embolization, which extends the neurological damage. With isolated carotid wounds, extensive monitoring is not usually required, but a radial arterial line is helpful for measurements for arterial blood pressure and bloodgas tensions. General anesthesia, hypercapnia and some neurological wounds interfere with cerebral autoregulation, and cerebral blood flow will then respond directly to changes in systemic arterial pressure. The maintenance of normal blood pressure is an important concept in the correct management of these situations. As in almost all cases of cervical trauma, the induction of anesthesia must be accomplished gently to prevent the dislodgment of tamponading clots, which might cause recurrence of bleeding or embolize into the intracranial circulation. But drugs that are likely to cause hypotension are not desirable and should be avoided. If the wound has not been accurately identified by preoperative arteriography, wide surgical exposure will be needed for exploration. The neurovascular structures are reached through the customary carotid incision made along the anterior border of the sternomastoid muscle, approaching the artery slightly from the anterolateral aspect to initially obtain control of the common carotid artery proximal to the area of suspected injury. Once the arterial wound is exposed, gentle digital pressure will usually control bleeding without clamping the vessel, thus minimizing the time of carotid artery occlusion. Injuries of the external carotid artery are usually clamped and repaired or ligated as indicated, and unless there is evidence that the external carotid artery is functioning as a major cerebral collateral, it often is sacrificed. Brisk, pulsatile backflow is usually evidence of adequate cerebral perfusion, but measurements of carotid artery stump pressures may be helpful. It has been suggested that back pressures greater than 70 mmHg indicate adequate cerebral perfusion; thus, such patients do not require additional support of cerebral circulation during the period of carotid artery occlusion necessary for repair. Unless the patient has multiple injuries or has injuries of the eye or central nervous system or has multiple fractures, most surgeons use systemic heparin when shunts are in place. However, it would seem more important to heparinize the patients if the distal carotid artery was filled with a stagnant pool of blood. Most studies of shunting and intraoperative heparinization during the repair of carotid artery injuries have failed to delineate clearly the need for and results of these maneuvers. This is especially important with blunt trauma because the wall damage is likely to be extensive. After resection, a repair without tension is required or an interposition graft is needed. Customarily, the saphenous vein is chosen to restore continuity in the carotid artery. Lacerations at the carotid foramen that are too high to allow the placement of a vascular clamp distally can be controlled by inserting a balloontipped catheter through a separate incision in the artery and then advancing the catheter beyond the laceration and gently inflating the balloon to control soft Fogarty catheters with attached three-way stopcocks, or special balloon occlusion catheters can be used for the carotid artery (these catheters are already in use so there is no need to design new ones). Blunt carotid injuries are generally caused by an injury mechanism that is associated with combined rotation and either hyperflexion or hyperextension of the neck. Delayed recognition of an occult vascular injury can Endovascular management of thoracic outlet and neck vascular trauma 763 have disastrous consequences and has been associated with a mortality rate of up to 50%. Nonocclusive dissections are known to resolve in 70% of patients with anticoagulation therapy alone, with the latter 30% developing pseudoaneurysms.

Angled bonecutting shears aid in dividing the fibula at a higher level than the tibia blood pressure normal zone order cheap cardura. Bleeding vessels and venous sinuses are suture ligated; it is important to achieve good hemostasis to avoid the formation of postoperative stump hematomas heart attack las vegas 1 mg cardura buy visa. Cross-sectional anatomy of the leg at level of below-knee amputation blood pressure ranges pediatrics cardura 2 mg otc, demonstrating position of major neuromuscular structures pulse pressure factors purchase 1 mg cardura fast delivery. Then the wound is irrigated and closed in two layers hypertension 2006 purchase 1 mg cardura mastercard, commencing with myoplasty of the posterior flap by suturing the tendinous cut edge of the gastrocnemius­soleus forward over the ends of the bone to the thinner anterior fascia and the periosteum of the tibia. Skin apposition must be precise, since delay of epithelialization is likely, because of the reduced vascularity, if there are any gaps between the skin edges. The sutureline scar should be above the bevelled anterior edge of the tibia, away from regions of pressure if possible. The author favours plastic excision of the dog ears with careful closure of the surgical wound at the time of amputation. The resultant hemicylinder provides the prosthetist with a suitable shape for the manufacture of a socket. Closed suction drains may be used if needed but are generally not necessary and increase the incidence of infection. There are many variations of definite below-knee prostheses from a simple pylon with a nonmotion foot to energy-storing prostheses. Compared to an age-adjusted normal population, there is a 40%­60% increase in energy expenditure for ambulation at this level of amputation. The distal supracondylar amputation and Gritti-Stokes techniques have lost popularity because of the realization that the through-knee amputation has the advantage of preserving proprioceptive areas of the joint and affords greater bone length, which makes manipulation of a prosthesis simpler. As with the below-knee amputation, myodesis procedures (except as described later), where the muscles are sutured or otherwise fixed to holes drilled in the bone, are generally not encouraged in the dysvascular patient. It is far simpler, just as functional, and probably allows fitting of a more cosmetic prosthesis to divide the muscles distal to the site of bone division and then to suture antagonistic groups over the end of the bone stump, anchoring them to each other and to the periosteum. A technique using laterally placed flaps is favoured for through-knee amputation in some centres,76 particularly if the anterior skin-flap region is compromised by ischemia. In addition, proprioceptive information coming from the capsular structures of the knee is preserved. It is hard to get cosmetic or matching knee centres, even with new 4-bar link knees. Since the residual limb is bulbous at the distal femur flares, the prosthesis must be made with a medial or posterior window, and therefore the prosthesis is not often very cosmetic. If a through-knee amputation is to be performed, the skin incision must be distal to the knee joint by 4­5 cm (level of the tibial tubercle), and the patella and patellar tendon are usually preserved and sutured over the exposed femoral condyles. Preferably the patient is placed prone and an anterior-based skin flap is created. The incision is deepened straight through to the depth of bone, perpendicular to the skin, and the muscles and tendons attached to the upper part of the tibia (sartorius, gracilis, semitendinosus, quadriceps expansion and gastrocnemius) are divided. The patellar tendon is separated from the tibial tubercle and the knee joint is entered anteriorly. The resection continues below the menisci, preserving the capsular attachments to the rims of the medial and lateral meniscus. The described joint incision helps to preserve the rich proprioceptive supply of the knee joint. With the knee bent, the posterior capsule of the joint is divided, giving access to the popliteal neurovascular structures. The artery and vein are suture ligated, and the nerves are brought down, ligated and then allowed to retract up into the muscle bulk. Surgical techniques of amputation 323 the patella is reflected back over the femoral condyles and may be held in place by suturing the infrapatellar tendon to the posterior capsule; however, if there is insufficient patellar tendon length, the tendon may be sutured to the stumps of the cruciate ligaments. Preservation of the patella and patellar tendon conserves the broad kneeling area of the knee. Compared to the normal age-adjusted population, there is a 100%­120% increase in energy expenditure for ambulation at this level of amputation. Above-knee amputation Because ambulation after above-knee amputation is directly related to bone length, this procedure is done with the aim of preserving the maximum possible bone length. The usual level of amputation is just above the terminal flare of the femur, allowing approximately 10 cm for the interposition of an artificial knee joint between the stump and the normal knee axis. We have usually used anterior and posterior flaps, but a circumferential incision is also suitable. Short flaps are preferred because of the possibility of jeopardizing blood supply in long flaps. The incision passes through the skin, subcutaneous tissue and deep fascia without undermining and then is continued obliquely through the muscle layers towards the anticipated line of bone section. As the major vessels are almost certainly occluded, hemorrhage is rarely a problem. The sciatic nerve is exposed more posteriorly and ligated after being pulled down, Superficial femoral vessels Gracilis S or Rec art emo tus f ris Profunda femoris vessels Femur Vastus Adductors Hamstrings Sciatic N. The bone is sectioned using a hand or electric saw, and the ends are smoothed with a file. Opposing muscle groups are then sutured over the end of the bone, with special attention being given to fixation of the rectus femoris and hamstrings to each other and to the periosteum to preserve balance of contractile function. The adductor magnus and fascia lata are sutured to each other transversely over the bone. Careful approximation of muscle layers also obliterates dead space within the wound. The fasciae of the anterior and posterior flap are then approximated with interrupted, absorbable sutures. If necessary, wound drainage may be instituted with a closed suction drain or a Penrose tissue drain placed at the base of the flaps. However, absolute hemostasis is worth the effort since drains increase the possibility of infection. The amputation dressing is then applied, and a plaster-of-Paris cast may be added, especially if a prosthesis is to be used immediately. One of the major prosthetic advances in the last two decades has been the move away from the quadrilateral socket (Berkeley brim) to the Catcam soft plastic socket fit for above-knee amputees. These new prostheses are lighter and more functional than their older counterparts and probably have helped to increase the percentages of ambulatory above-knee amputees. However, compared to an age-adjusted normal population, the increase in energy expenditure required to ambulate after an above-knee amputation ranges from 140% to 200%. Since the use of a wheelchair requires only a 9% increase in energy expenditure, it is easy to understand why elderly amputees, especially those with cardiovascular impairment, choose a wheelchair over walking with an above-knee prosthesis. The above-knee amputation is performed utilizing a long medial flap and shorter lateral flap in order to preserve length of the adductor magnus muscle. The adductor magnus is dissected off the distal medial femur, and after transection of the femur, the adductor magnus is wrapped over the end of the femur and then fixed to the lateral femur in a true myodesis. The medialbased skin flap allows closure of the incision on the lateral side of the leg without skin tension. Most commonly in dysvascular patients, this amputation is performed in the face of occlusion of the common femoral, superficial femoral and profunda femoral arteries. Because of poor blood supply, healing complications and stump infection are common when this amputation is performed in dysvascular patients. In hip disarticulation amputation, the initial step is control of the femoral artery, followed by division of the musculature of the adductor and anterolateral compartments to expose the hip joint. Needless to say, most amputees (except children) do not ambulate at this level of amputation and use a wheelchair for mobility. Patients should go to physical therapy for range-of-motion and limb-strengthening exercises starting on the first postoperative day if possible. The dressing is usually not disturbed for 3 or 4 days unless there is significant pain or fever pointing to possible complication. In those instances where drainage tubes are necessary, they are removed as soon as possible, preferably within 24 hours. We prefer not to suture the drains in place, so that they may be removed gently without disturbing the dressing. The elastic stump bandage helps prevent swelling while also allowing for passive and active exercise in order to avoid contractures. Conditions such as diabetes mellitus, hypertension, heart disease and chronic respiratory disorders require close monitoring and control during the postoperative period. Systemic antibiotics should be continued for several days if infection was present at the time of operation; in the absence of infection, several perioperative prophylactic doses of antibiotic are sufficient (24 hours). The rehabilitation of the patient commences as soon as possible and is best achieved using a multidisciplinary approach, involving regular instruction and supervision by a physical therapist, occupational therapist, prosthetist and surgeon. The patient is instructed in the proper technique of bandage application and should reapply the bandage several times a day. Correct technique is important in preventing circumferential compression, which may increase edema. Narcotic analgesia will usually be required for several days; however, complaints of severe pain after 48 hours suggest a major complication and should precipitate removal of the dressing and inspection of the wound. Postoperative confusion is common because of the generally elderly population that one is dealing with and because of factors such as infection, analgesia and multiorgan disease. If the patient is confused, steps must be taken to prevent him or her from trying to get out of bed, which often precipitates injury to the amputation stump. Other advantages have been noted with early prosthesis fitting, including better control of edema of the stump, less pain, perhaps earlier healing, protection of the wound from trauma, improved rates of rehabilitation and prevention of contractures. The earlier mobilization is thought to be associated with a lower incidence of venous thromboembolic disease, atelectasis and pneumonia. Patients have been noted to regain strength and to show earlier learning of balance control due to the increased proprioceptive input from muscles and joints of Immediate postoperative prosthesis fitting 325 the involved limb, which occurs with early mobilization, exercise and partial weight bearing. Obviously, this technique will not be suitable for all patients, especially those who have been severely debilitated by sepsis or long-term illness. However, with objective preoperative selection of amputation level, wound-healing problems can be reduced to a minimum. Because this technique requires the patient to wear a plaster cast over the amputation stump for 2­3 weeks, it should not be used for those patients who may be vulnerable to wound breakdown or possible infection, since the stump will then not be readily accessible for inspection. A window is made in the cast over the patella to protect this area from pressure sores and to allow patellar movement with ambulation. Immediate postoperative prosthetic techniques work well with all levels of major limb amputation (transmetatarsal amputation, Syme, the Scottish surgeon, below knee or above knee) but work best with below-knee amputees. If the patient is well enough, mobilization may commence on the first postoperative day. On the first postoperative day, the patient stands at bedside without weight bearing. During the first week the patient progresses to standing without placing weight on the prosthesis while supported by a walking frame or crutches. By the second week the patient advances to 50% weight bearing on the amputated limb, and full weight bearing is achieved by 21­30 days after surgery. The team of prosthetist, physical therapist and surgeon supervises and encourages the patient with most of the early exercises and use of the prosthesis. The rehabilitation process is best supervised in the physical therapy department, where special equipment for ambulation, such as parallel bars, is available. The patient progresses from standing and balancing with limited ambulation through progressive weight bearing over several weeks as previously described. After the second or third cast change, the patient makes use of temporary removable prostheses until full wound healing and moulding of the stump have occurred, at which time measurements for the permanent prosthesis may be taken and the permanent prosthesis manufactured (usually at 6 months). Several follow-up studies have shown that approximately 50% of the diabetic amputee patients die within 2­3 years of the operation, usually because of cardiac or cerebrovascular problems, and that, of the survivors, a further 30%­50% eventually require amputation of the contralateral leg within the same time span. Until recent years, the operative mortality rate among those with amputations below the knee was approximately 10%, and among those with through-knee or above-knee amputation, the usual rates were 20%­30%. Bodily and Burgess87 reported a series of 55 patients who had major amputations with an operative mortality rate of only 1. There is also a relatively high incidence of postoperative cardiovascular and cerebrovascular complications such as myocardial infarction, stroke or respiratory failure. If the amputation is performed for the treatment of sepsis, infective complications including septicemia and multiorgan failure may be common. A high incidence of postoperative venous thrombosis has been reported, particularly for amputation above the knee. The success rates with rehabilitation diminish dramatically in any patient who has been at bed rest for more than 30 days prior to major lower extremity amputation. Neurological changes such as confusion, disorientation and reactive depression frequently occur and may be difficult to manage while also rendering rehabilitation difficult. Care of the skin wound is compromised in these patients, and they may require special observation to prevent accidents such as falling out of bed, which often leads to breakdown of the stump. Other common general complications include urinary tract infection and urinary retention, sacral-pressure-area bed sores, gastrointestinal bleeding and renal failure. These problems can be minimized by good objective selection of amputation level prior to surgery, preoperative treatment for infected ischemic limbs and the use of antibiotic prophylaxis. However, even with ideal management, episodes of skin-flap ischemia and sutureline infection cannot always be avoided. However, amputation level selection by objective tests (such as Ptc O2) will minimize postoperative healing failures. This situation can often be salvaged by excision of all the necrotic tissue and primary closure, still at the below-knee level. Phantom pain occurs frequently, and the patient should be warned of this possibility before surgery. Usually, the symptoms are not severe and no specific treatment is necessary, but occasionally narcotic or antidepressant medication may be required.

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If such incisions are used blood pressure medication lip discount cardura online mastercard, the location of the femoral bifurcation should be identified preoperatively prehypertension wiki order cardura toronto. The anastomoses are generally placed in the distal common femoral artery over the take off of the profunda femoris artery pulse pressure 67 discount cardura 2 mg without a prescription. In cases with a concomitant superficial femoral artery occlusion hypertension vitals cardura 4 mg order, the anastomosis can still be placed onto the common femoral artery arrhythmia and pregnancy cardura 1 mg order mastercard, provided there is no stenosis of the profunda femoris artery. If there is an orificial stenosis, the distal anastomosis can be used to perform a profundoplasty, with the heel of the anastomosis over the common femoral artery and the toe onto the profunda femoral artery. If the common, superficial and deep femoral arteries are all occluded, direct reconstruction to the popliteal artery may be required. Once the vessels are exposed, a long, standard tunnelling device is used to create a tunnel between the axilla and the groin. The graft must initially take a lateral course under the pectoralis major and away from the axillary anastomosis before heading caudally in the subcutaneous tissue along the anterior axillary line. It then courses anteromedially over the iliac crest and inguinal ligament to the groin. The use of a counter incision below the inferior aspect of the pectoralis major on the chest wall facilitates tunnelling along the abdominal wall, thereby avoiding inadvertent injury to the abdominal contents. In the cases when a bifemoral bypass is being performed, a suprapubic tunnel for the crossover bypass is made in the subcutaneous space over the inguinal ligaments with either a tunnelling device or large aortic clamp. An 8 mm graft is preferred; however, a 6 mm graft may be used in patients with small arteries without compromising patency. The graft is passed through the tunnels and the patient is systemically heparinized. It is essential that the graft not be made too short in order to avoid undue tension on the anastomoses, as well as not too long to prevent redundancy and possible kinking of the graft. We prefer to leave external ring supports to within 1 cm of the anastomosis as a further protection against kinking. Arteriotomies are made (b) to ensure appropriate inflow and outflow, often involving deep femoral artery reconstruction. The graft must be carefully placed in the subcutaneous tunnel to avoid kinking (lower right). This is essential to reduce tension on the anastomosis and avoid graft dehiscence. The axillary artery is generally soft and delicate, so it should be handled with care when dissecting or suturing to avoid tearing of the vessel. The anastomosis can be constructed either in standard fashion from heel and toe towards the centre of the arteriotomy, or the suture can be initiated at the midpoint of the posterior aspect of the anastomosis and run towards the heel and toe. In either case, it is essential to ensure that the posterior suture line is secure and without gaps because this area is difficult to repair after the suture line is completed. The femoral anastomosis is sewn in standard fashion, beginning with the heel and proximal half of the anastomosis, and then completing the distal anastomosis with the toe suture. We prefer to use a subcuticular closure for all skin incisions, as staples and exposed sutures can catch clothing, requiring dressings until removed. There are now preformed grafts available with the femoral­femoral graft already attached to the axillary graft limb. Using such grafts reduces the total number of anastomoses from four to three, thereby reducing operative time. Femorofemoral bypass 305 Results the overall 5-year patency for axillobifemoral grafts, once as low as 30%­40%, is now as high as 60%­80% since the introduction of externally supported grafts. Although this effect has not proven by direct comparison, the use of externally supported grafts has been widely adopted on the basis of these theoretical advantages. Patients undergoing axillobifemoral bypass for infected abdominal grafts originally placed for aneurismal disease, without concomitant occlusive disease, can be expected to have better patency than for patients for whom the grafts were placed for severe occlusive disease. Axillobifemoral bypass grafts are suggested to have a better 5-year patency than the axillounifemoral grafts, presumably because of the increased flow rate in the axillary limb. Occlusions of the superficial femoral artery may reduce the patency of the bypass. We generally perform these procedures under direct fluoroscopic guidance for several reasons. First, the chance of injury to the native vessel is reduced by preventing overdistention of the balloonthrombectomy catheters. Second, it allows the surgeon to identify and possibly treat any underlying inflow or outflow lesions with an endovascular approach. When comparing reports in the literature regarding axillofemoral bypass grafts, it is important to note that there is considerable variability in the techniques used and the outcome measures defined, for example primary versus secondary patency. In addition, it must be noted whether graft components are considered separately in patency calculations, as some authors may consider the axillofemoral and the femorofemoral components as distinct grafts. Post-operative management Patients are placed on an anti-platelet agent if not already on one preoperatively. Anticoagulation with Coumadin is reserved for patients with a known hypercoagulable state or in whom a secondary procedure was required to reestablish patency. As in all patients with peripheral artery disease, the use of a statin is recommended. Graft surveillance is performed every 3 months for the first year, every 6 months for the second year and yearly thereafter. The need for a subsequent intervention or other abnormal findings on duplex may necessitate more frequent surveillance. In these cases, the aorta or contralateral femoral artery may serve as the donor vessel. Conditions precluding the aorta as the vessel of choice make the contralateral femoral artery a favoured candidate. Considerations to undertake a femorofemoral bypass are similar to those for an axillofemoral bypass: anatomic factors such as an unsuitable aorta as a donor vessel, patient factors such as co-morbid conditions making the patient at high risk for open abdominal surgery and indications such as chronic arterial ischemia or another disease process affecting a unilateral iliac system. Patient evaluation encompasses a thorough history and physical examination, which is further supported by non-invasive testing. It is worth noting that endovascular approaches may be worth considering, or perhaps, have failed, in the patient being evaluated for a femorofemoral bypass. The tunnel is placed in a suprapubic location in the subcutaneous space over the inguinal ligaments with either a tunnelling device or large aortic clamp. Both ends of the graft are beveled and the anastomosis is created with the toes pointing cranially. The graft courses caudally in each groin, turns laterally, before continuing cranially to the anastomosis. The inferior curve of the graft at both anastomoses acts as a hinge, transferring pressure off the anastomosis as the pannus moves with transition from the lying to the sitting or standing position. Thus, this orientation prevents kinking of the graft and reduces the risk for anastomotic disruption. The risk of graft infection is especially problematic because the majority of patients undergoing these procedures already have limited reconstructive options and significant medical co-morbidities. Another potential complication is injury to intrathoracic or intraabdominal contents during tunnelling of the graft. As noted earlier, care must be taken to avoid injury to other neurovascular structures such as the axillary vein or brachial plexus. Reconstruction to the level of the contralateral popliteal artery may be accomplished using a single in line or crossover graft with similar patency rates. Complications specific to femorofemoral bypass are wound infections given the location of the incision in the groin; as such, it is important to keep the incisions dry to prevent skin maceration and wound dehiscence, which may secondarily infect the graft. Seromas, lymph leaks and bladder injury during the tunnelling process have also been described. Results the reported patency rates of femorofemoral bypass grafts at 5 years have been reported between 60% and 80%. In a randomized study comparing direct versus crossover bypasses for unilateral iliac artery disease, direct reconstruction offered superior primary patency rates at 5 years, 92% versus 73%, respectively. The secondary patency rates were significantly improved, Other extra-anatomic bypasses 307 but still inferior to direct revascularization, 97% versus 90%. Multiple factors have been shown to influence graft patency rates for crossover femorofemoral bypasses. Mingoli and colleagues reported superior patency rates with externally supported grafts compared to those without: 5- and 10-year rates were 80. Lipsitz and colleagues reported a 95% 4-year primary patency rate when the bypass was performed in conjunction with aorto-uni-femoral endovascular graft placement for aneurysmal disease. The descending thoracic aorta may also be accessed with a minimal thoracotomy, less than 8 cm in length, along the ninth rib interspace. When the thoracic aorta is used for inflow, the tunnel may course along the lateral abdominal wall. Five-year patencies have been reported more than 80% with minimal perioperative mortality. This approach is reserved as an alternative for a good-risk patient, where the abdominal aorta may not be able to serve as the ideal inflow due to the anatomic factors. The obturator internus muscle is divided along the direction of its fibres and the underlying fascia is divided. The outflow is the distal superficial femoral artery or popliteal artery at the level of the adductor hiatus. Next, a tunnelling instrument is used to pass the graft from the obturator foramen and adductor hiatus. Long-term results for obturator bypasses are limited, but available series in the literature report promising results. For many reasons, it is the preferred or only viable option for patients with significant anatomic or medical co-morbidities, which preclude standard bypass options. Axillofemoral and femorofemoral bypasses can be performed with acceptable morbidity, mortality and long-term results, even in high-risk patients. For these reasons, surgeons should be familiar with the indications and application of this technique. Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: A systematic review and metaanalysis. A contemporary comparison of aortofemoral bypass and aortoiliac stenting in the treatment of aortoiliac occlusive disease. Long-term outcome after treatment of aortic graft infection with staged extraanatomic bypass grafting and aortic graft removal. Unsuspected inflow disease in candidates for axillofemoral bypass operations: A prospective study. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. Clinical results of axillobifemoral bypass using externally supported polytetrafluoroethylene. Comparative evaluation of externally supported Dacron and polytetrafluoroethylene prosthetic bypasses for femorofemoral and axillofemoral arterial reconstructions. A comparative evaluation of externally supported polytetrafluoroethylene axillobifemoral and axillounifemoral bypass grafts. Is axillo-bilateral femoral graft an effective substitute for aortic-bilateral iliac/femoral graft Femorofemoral bypass to the deep femoral artery for limb salvage after prior failed percutaneous endovascular intervention. Femorofemoral bypass as an alternative to a direct aortic approach in daily practice: Appraisal of its current indications and midterm results. Long-term results of a multicenter randomized study on direct versus crossover bypass for unilateral iliac artery occlusive disease. Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome. Patency rates of femorofemoral bypasses associated with endovascular aneurysm repair surpass those performed for occlusive disease. A bypass hemograft from thoracic aorta to femoral arteries for occlusive vascular disease: A case report. Descending thoracic aorta to iliofemoral artery bypass grafting: A role for primary revascularization for aortoiliac occlusive disease Thoracic aortobifemoral bypass in treatment of juxtarenal Leriche syndrome (midterm results). Obturator bypass: A classic approach for the treatment of contemporary groin infection. The obturator foramen bypass: An alternative procedure in iliofemoral artery revascularization. Transobturator aorto-profunda femoral artery bypass using the direct medial thigh approach. The higher mortality usually associated with above-knee amputation is due to more severe and widespread cardiovascular diseases in that group of patients. More than 70% of patients requiring amputation for peripheral vascular disease have other major systemic manifestations of atherosclerosis. In the United Kingdom, approximately 65,000 amputees are known to the Department of Health and Social Security, with 6,000 new patients being referred to limb-fitting centres annually. Diabetes mellitus is the underlying disease for amputation in more than two thirds of cases. In general terms, the indications for amputation in the dysvascular patient are (1) complication of diabetes mellitus, (2) nondiabetic infection with ischemia, (3) osteomyelitis, (4) trauma, (5) failed limb salvage operations and (6) failed minor amputation. Although above-knee amputation does carry a higher operative mortality risk than below-knee amputation,1,2 Rush et al. If the patient has presented 311 312 Amputation in the dysvascular patient late, with irreversible tissue loss accompanied by systemic toxicity, with or without myonecrosis, urgent amputation is indicated. Urgent amputation is also the treatment of choice if there is extensive or invasive infection. In elderly patients with sepsis, physiologic amputation rather than urgent surgical amputation may be an important first step in lowering patient mortality.

Surgical revascularization achieves excellent limb salvage rates; however hyperextension knee generic cardura 1 mg with amex, patient co-morbidities arrhythmia institute generic cardura 1 mg with mastercard, local tissue considerations and technical expertise often reduce its clinical applicability hypertension 4 year old order cheap cardura line. Endovascular treatment offers an attractive alternative due to its minimally invasive nature hypertension vitals buy cheap cardura 4 mg line. Diabetic lesions are often long pre hypertension natural cure discount cardura 2 mg on line, calcified segmental occlusions affecting more than one crural vessel. Concomitant iliac and femoral artery disease may occur, but rarely in the absence of below-the-knee disease. Short tibial occlusions can be easily crossed intraluminally, but a subintimal technique is more applicable for longer (>3 cm) occlusions. Technical success rates are reported in excess of 90% but vary considerably reflecting institutional experience. Patients with two or more patent run-off vessels have three times less risk of occlusion compared to those with one patent run-off vessel. Occlusion following successful subintimal recanalization does not necessarily cause clinical deterioration. Lower limb diabetic ischaemic ulceration is very rarely secondary to acute or acute-on-chronic arterial occlusion. The majority occurs as a result of disequilibrium between a finely balanced tissue oxygenation demand and supply. Arterial disease is often long standing, but adequate to maintain tissue integrity. Minor injuries resulting in increased tissue oxygen demand alter this equilibrium setting into motion a cascade effect. This theory is supported by clinical studies paradoxically reporting patency rates of 70% at 12 months, but limb salvage rates between 80% and 90%. A patient with multi-segment occlusions and single vessel run-off with a life expectancy >24 months and is deemed physiologically fit to undergo surgery should be offered a bypass procedure if adequate vein is available. Likewise, unfit patients with limited life expectancy or no suitable vein should be considered for an endovascular first strategy. We always ask the question: is the going to live long enough for the increased shortterm risks associated with bypass surgery to be offset by the improved long-term outcome Type 2 diabetes in children and adolescents: Risk factors, diagnosis, and treatment. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States. Update on some epidemiologic features of intermittent claudication: the Framingham Study. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Risk of mortality and cardiovascular disease associated with the anklebrachial index: Systematic review. Nitric oxide reversibly inhibits the migration of cultured vascular smooth muscle cells. The vascular endothelin system in obesity and type 2 diabetes: Pathophysiology and therapeutic implications. Impaired free fatty acid utilization by skeletal muscle in non-insulindependent diabetes mellitus. Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: An individual participant meta-analysis. Hemostatic factors as predictors of ischemic heart disease and stroke in the Edinburgh Artery Study. Coagulation, fibrinolysis, and platelet activation in patients undergoing open and endovascular repair of abdominal aortic aneurysm. Clinical, haemodynamic, rheological, and biochemical findings in 126 patients with intermittent claudication. Haemostatic function and ischaemic heart disease: Principal results of the Northwick Park Heart Study. Impact of diabetes-associated lipoproteins on generation of fibrinolytic regulators from vascular endothelial cells. Protein C deficiency in insulin-dependent diabetes: A hyperglycemia-related phenomenon. Impaired nitric oxide-mediated vasodilation in patients with non-insulin-dependent diabetes mellitus. Impaired endothelium-dependent and independent vasodilation in patients with type 2 (non-insulindependent) diabetes mellitus. Peroxisome proliferator-activated receptor delta regulates extracellular matrix and apoptosis of vascular smooth muscle cells through the activation of transforming growth factor-beta1/Smad3. Adenosine transport, erythrocyte deformability and microvascular dysfunction: An unrecognized potential role for dipyridamole therapy. Microvascular function in Type 2 (non-insulindependent) diabetes: Improved vasodilation after one year of good glycaemic control. Screening for abdominal aortic aneurysms and associated risk factors in a general population. Prevalence and associations of abdominal aortic aneurysm detected through screening. Abdominal aortic aneurysm and aortic occlusive disease: A comparison of risk factors and inflammatory response. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms. Matrix biology of abdominal aortic aneurysms in diabetes: Mechanisms underlying the negative association. High glucose increases growth and collagen synthesis in cultured human tubulointerstitial cells. Evidence for a matrix metalloproteinase induction/activation system in arterial vasculature and decreased synthesis and activity in diabetes. Cross-linking of glycated collagen in the pathogenesis of arterial and myocardial stiffening of aging and diabetes. Diabetes as a negative risk factor for abdominal aortic aneurysm ­ Does the disease aetiology or the treatment provide the mechanism of protection Peroxisome proliferator-activated receptor ligands reduce aortic dilatation in a mouse model of aortic aneurysm. The effects of treatment with drospirenone/ethinyl oestradiol alone or in combination with metformin on elastic properties of aorta in women with polycystic ovary syndrome. Rosiglitazone reduces the development and rupture of experimental aortic aneurysms. Parlani G, De Rango P, Cieri E, Verzini F, Giordano G, Simonte G, Isernia G, Cao P. Diabetes is not a predictor of outcome for carotid revascularization with stenting as it may be for carotid endarterectomy. Acta impact of diabetes mellitus on characteristics of carotid plaques and outcomes after carotid endarterectomy. Metabolic syndrome: A predictor of adverse outcomes after carotid revascularization. Foot ulceration and lower limb amputation in type 2 diabetic patients in Dutch primary health care. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2. Prediction of outcome in individuals with diabetic foot ulcers: Focus on the differences between individuals with and without peripheral arterial disease. Clinical characteristics and outcome in diabetic patients with deep foot infections. Diagnosing diabetic foot osteomyelitis: Is the combination of probe-to-bone test and plain radiography sufficient for high-risk inpatients The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: Metaanalysis. Decline in neurophysiological function after 7 years in an adolescent diabetic cohort and the role of aldose reductase gene polymorphisms. Transcutaneous oxygen tension measurements on limbs of diabetic and nondiabetic patients with peripheral vascular disease. Venous oxygenation in the diabetic neuropathic foot: Evidence of arteriovenous shunting Peripheral arterial disease and risk of cardiac death in type 2 diabetes: the Fremantle Diabetes Study. The annual incidence of diabetic complications in a population of patients with Type 1 and Type 2 diabetes. Paradoxically lower prevalence of peripheral arterial disease in South Asians: A systematic review and meta-analysis. Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. Peripheral arterial disease in diabetic and nondiabetic patients: A comparison of severity and outcome. Incidence of lower-limb amputation in the diabetic and nondiabetic general population: A 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations. Outcome of ischemic foot ulcer in diabetic patients who had no invasive vascular intervention. Long-term prognosis of diabetic patients with critical limb ischemia: A population-based cohort study. The use of noninvasive vascular assessment in diabetic patients with foot lesions. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Early revascularization after admittance to a diabetic foot center affects the healing probability of ischemic foot ulcer in patients with diabetes. Noninvasive localization of arterial occlusive disease: A comparison of segmental Doppler pressures and arterial duplex mapping. Diagnosis of arterial disease of the lower extremities with duplex ultrasonography. Diagnostic performance of computed tomography angiography in peripheral arterial disease: A systematic review and meta-analysis. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Technology Insight: Magnetic resonance angiography for the evaluation of patients with peripheral artery disease. Use of magnetic resonance angiography for the preoperative evaluation of patients with infrainguinal arterial occlusive disease. Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency. Impact of diabetes mellitus on outcomes of superficial femoral artery endoluminal interventions. Safety of vein bypass grafting to the dorsal pedal artery in diabetic patients with foot infections. A decade of experience with dorsalis pedis artery bypass: Analysis of outcome in more than 1000 cases. Angiosomes of the 267 foot and ankle and clinical implications for limb salvage: Reconstruction, incisions, and revascularization. Worse limb prognosis for indirect versus direct endovascular revascularization only in patients with critical limb ischemia complicated with wound infection and diabetes mellitus. Results of infrapopliteal endovascular procedures performed in diabetic patients 141. Systematic review and meta-analysis of direct versus indirect angiosomal revascularisation of infrapopliteal arteries. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. Factors influencing wound healing of critical ischaemic foot after bypass surgery: Is the angiosome important in selecting bypass target artery Riskscoring method for prediction of 30-day postoperative outcome after infrainguinal surgical revascularization for critical lower-limb ischemia: A Finnvasc registry study. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, Mingardi R, De Giglio R. Vascular involvement in diabetic subjects with ischemic foot ulcer: A new morphologic categorization of disease severity. Recanalization of femoropopliteal occlusions: Improving success rate by subintimal recanalization. Percutaneous intentional extraluminal recanalisation of the femoropopliteal artery. Sub-intimal angioplasty of long chronic total femoropopliteal occlusions: Long-term outcomes, predictors of angiographic restenosis, and role of stenting. Subintimal angioplasty: Our experience in the treatment of 506 infrainguinal arterial occlusions. Subintimal angioplasty for the treatment of claudication and critical limb ischemia: 3-year results.

The most recent trials now document progressive renal impairment in around 20% with less than 8% needing renal replacement therapy pulse pressure in neonates order cheap cardura on-line. This observation hypertension 130 90 purchase cardura with american express, particularly in the days of inefficient and poorly tolerated antihypertensive agents blood pressure medication yellow pill order cardura 2 mg on-line, led to the concept that overcoming reduced renal blood flow by revascularization would cure hypertension blood pressure medication diltiazem cardura 2 mg low cost. This simple association however has been shown to be present in only a small percentage of such patients with the realization that the pathophysiology is much more complex blood pressure chart in canada buy cardura on line. Early studies implicated changes within the contralateral normal kidney in successfully revascularized patients but with persistent hypertension. Clinical presentation occurs after many years and perhaps decades of progressive arteriosclerosis and poorly controlled hypertension. This significantly increases the likelihood of chronic change taking place within the parenchyma not only of the affected but also the contralateral kidney. Arterial blood flow is compromised only when a stenosis is >70% or if there is a significant trans-lesional gradient of 10­20 mmHg, and renal vein renin studies confirm elevated renin production only in these scenarios. Textor and colleagues suggest however that even in the presence of low-grade stenosis, renal hypo-perfusion will develop because frequently there are fluctuating arterial pressures and impaired cardiac output. This recent hypothesis proposes that repeated intermittent episodes of acute kidney injury are frequent but from which the kidney can recover, however, inducing a state of chronic inflammation within the renal parenchyma. Support for this hypothesis is found in the chronically elevated bio-markers for injury such as neutrophil gelatinase­associated lipocalin, measured in renal vein sampling. This hypothesis provides a likely explanation for the chronic parenchymal changes associated with atherosclerotic renovascular disease even in the presence of moderate stenosis or well controlled hypertension. Further insights into the pathophysiology of ischaemic nephropathy have been provided recently from the Mayo Clinic. These focused on understanding tissue deoxygenation and microvascular injury in atherosclerotic renovascular disease. All patients had standardized antihypertensive drug therapy and sodium balance correction. These studies showed large tissue oxygenation gradients, with low levels of deoxyhemoglobin in the cortex with areas of higher deoxygenation in the deeper medulla. These studies indicate that even in the presence of severe inflow stenosis, the kidney is able to preserve normal tissue oxygenation, most probably because blood flow to the kidney has a dual purpose, not only to meet parenchymal metabolic requirements but also as a filtering organ. Tissue biopsies performed in these patients revealed structural damage involving the glomeruli and tubules but also marked interstitial inflammatory cell infiltration particularly from T cells and macrophages. Thus, once the degree of stenosis has become severe enough to induce cortical hypoxia, severe inflammatory injury develops which appears to become chronic. Thus, ischaemic nephropathy results from complex interactions only beginning to be understood involving oxidative stress injury, a chronic inflammatory reaction and parenchymal arteriosclerotic damage, leading to fibrosis of the glomerulus and tubular structures. In general, nonatherosclerotic causes of renovascular disease should be considered in younger patients presenting with hypertension but in the over 50s being much more likely to be secondary to arteriosclerotic renovascular disease. Careful consideration must be given to a further diagnostic and investigation of a patient presenting with hypertension. In a patient under the age of 30 years presenting with hypertension, the probability of an underlying renovascular lesion is higher, and the threshold for further investigation should be set lower. In a patient over the age of 50 years, however, the prevalence of an underlying renovascular condition is much lower. Careful selection for further diagnostic evaluation should be based on the clinical features, particularly those indicating the presence of arteriosclerosis. Unfortunately no marker that performs satisfactorily has been identified thus far. This value is a good marker for systemic burden of arteriosclerosis but has not proved to be of prognostic value in renovascular disease. In the majority of centres, it is the primary screening tool in the assessment of renovascular disease providing both functional and structural information. It has disadvantages relating to operator experience, but also to obesity and the presence of bowel gas. Nonetheless, it remains a valuable screening tool but also of value in sequential follow-up of patients following a revascularization. Renal duplex assessment should be performed by fully trained vascular scientists or technologists in accredited vascular laboratory with full imaging of the aorta and renal artery using a flank approach. With the clinical evidence which has now become available together with the much more effective and well tolerated range of hypertensives, this diagnostic decision-making has become more complex. If a patient has hypertension that is easily and successfully controlled and where renal function remains stable, the need for extensive diagnosis evaluation is increasingly considered to be of academic interest. General functional assessment of patients with hypertension and certainly patients with renal failure will obviously include the careful history and physical examination. Particular attention should be paid to the possibility of concomitant arterial disease particularly involving the carotid, cerebral vascular and peripheral circulations. In addition to standard haematological investigations, urinalysis is important; a 24-hour urine collection for a creatinine clearance is standard. However, there has been considerable concern expressed regarding the accuracy of this measurement in sequential analysis. In addition to providing a 3D image, the cross-sectional imaging gives a full assessment of the kidney itself. The first is that it does not provide functional assessment of renal artery stenosis. Thus, renal tissue which has impaired oxygen supply but is metabolically active will produce more deoxyhemoglobin. Further evaluation of this technique is underway and may provide a valuable methodology to select those patient subgroups that would benefit from renal revascularization. Furthermore, there are the risk of aortic and renal artery dissection and the significant nephrotoxic risks of contrast agents in renal injury or failure. The disadvantages are significant artefact in the presence of metal, particularly stents, and the absolute contraindication of pacemakers, implantable defibrillators, brain aneurysm clips or metal fragments in the eyes. Congestive heart failure, which can be present in patients with severe renal artery stenosis, is also a relative contraindication. However, with appropriate pre-investigation protocols of hydration, the use of peri-investigation dialysis in patients in end stage renal failure and the use of the more recent preparations of gadolinium, these risks have been significantly reduced. This methodology is based on the presence in deoxyhemoglobin of four free iron electrons making this molecule paramagnetic. This allows mapping across the kidney with the ability to distinguish between different regions and detect alterations in oxygen consumption. Captopril renography is no longer used as a diagnostic test because of poor sensitivity and specificity ranging from 58% to 95% and 17% to 100%, respectively. Furthermore, this test does not distinguish between unilateral and bilateral renal artery stenosis. Mercaptoacetyltriglycine renography continues to have a role however in defining the relative function of each kidney before revascularization or even nephrectomy. Segmental renal vein renin measurements have performed better with regard to predicting response to revascularization. However, given the need for more selective selection for renal revascularization in the modern era, this measurement may merit further prospective study. With the current range of well tolerated and safe antihypertensive agents, nowadays this rarely presents a therapeutic problem. In most non-atherosclerotic causes of renovascular disease, revascularization, either endovascular or vascular, is a secondary but curative treatment. In atherosclerotic renovascular disease, however, it is now clear that most patients will not benefit from revascularization. Atherosclerotic renovascular disease requires treatment not solely on maintaining blood pressure below the guideline recommended 130/90 mmHg and maintaining of renal function, but most importantly with a focus on reduction of cardiovascular events by treatment of generalized atherosclerosis. Inhibition of the renin­angiotensin cascade is now recognized to be highly effective, not only in the control of hypertension but also in the optimization of cardiac function and endothelial cell function. A minority of patients, particularly with bilateral renal artery stenosis, will suffer a decline in renal function resulting in an increase in serum creatinine of more than 30% ­ this possibility mandates careful review of patients after starting on renin­angiotensin inhibitors or blockers. Treatment of hyperlipidaemia is a further extremely important feature in the management of these patients. The cardiovascular protective effects of antiplatelet treatment outweigh the small risk of bleeding complications, particularly in patients with chronic kidney disease. Revascularization however remains important in the treatment of non-atherosclerotic renovascular disease where long-term improvement or even cure in control of hypertension and preservation of renal function can be expected. In non-atherosclerotic renovascular disease, the patients are typically younger and fitter; thus, in this group of patients, open surgical repair remains the gold standard (Table 40. Furthermore, these patients may have a cardio-renal syndrome with pulmonary oedema. Meticulous preoperative assessment with input from cardiology, nephrology and vascular anaesthesia is of vital importance in selecting surgical candidates. Lifestyle modifications most importantly with regard to smoking, exercise Revascularization 595 table 40. Indications for open surgical repair in patients Complex renal anatomy: segmental stenotic disease, multiple renal arteries Failed angioplasty/stent angioplasty: failed deployment, dissection, stent restenosis Severely diseased aorta Hybrid repair of thoraco-abdominal aneurysm high-volume centres, have reported lower operative mortality rates between 3% and 6%. However, operative mortality in the United States using data from the National Inpatient Sample was reported in 2008 as being closer to 10% ­ this represents mortality across a range of centres and is quoted by many experts as being a more realistic assessment of surgical risk. These data further reinforce the importance of surgical intervention being undertaken in high-volume specialist centres (Table 40. There are a range of operative approaches which can be tailored to the individual diagnosis, vascular anatomy and patient-specific risk. In patients with segmental renal arterial disease, bench reconstruction with auto-transplantation is a reliable procedure with acceptably low morbidity and mortality. Combined aortic reconstruction and renal revascularization should, if at all possible, be avoided because of the increased associated mortality. In the hands of most surgeons, this is regarded as a more complex approach with a particular disadvantage of the need for complete aortic cross clamping and increased left ventricular strain. Finally, nephrectomy of a small kidney (<8 cm in length) in a patient with refractory hypertension will infrequently be indicated. Laparoscopic nephrectomy is now established as of equivalent safety to open, with markedly reduced morbidity. As interventional experience gathered, it was realized that mortality rates were lower than open surgery but at the price of a higher technical failure rate of around 50% from both elastic recoil and in-stent restenosis. This elastic recoil was recognized to be secondary to the preponderance of ostial stenoses ­ essentially extensive calcified aortic wall disease involving the renal artery origins. As previously discussed, during this same period, pharmacotherapy for treatment of arteriosclerosis and hypertension had progressed significantly. The results of these trials indicated a benefit in terms of reduced antihypertensive medication but with a probable higher risk of complications for intervention. The numbers involved were small with systematic analysis yielding largely inconclusive results. Only patients where there was uncertainty or equipoise regarding a benefit from revascularization were included. No difference in blood pressure control either systolic or diastolic was found, there was no difference in preservation of renal function, and there was no difference in cardiovascular events or mortality. At on-table angiography, overestimation of stenosis was found in 20% of patients previously randomized to intervention at time of diagnosis when the stenosis was found to be <50%, and therefore, these patients did not undergo revascularization. This significant failure of randomization together with the specific exclusion from randomization of patients in whom the clinician felt that intervention was positively indicated were major flaws in this otherwise large prospective randomized study. Improved blood pressure control was found in four recent trials, however, with the improvement being noted in both the interventional and non-interventional limbs. For stent insertion, a long 6F sheath is used to catheterize the renal arteries with a 4F C1 catheter and hydrophilic 035 hydrophilic guidewire, then exchange for a stiffer wire such as a 035 Rosen or 035 Terumo Advantage. Some use pre-dilation with a simple angioplasty balloon before placement of a stent, but our usual practice is a primary stent deployment using a balloon expandable uncovered stent thus minimising the risk of embolization. Where there is doubt about the severity of renal artery stenosis a trans-stenotic pressure gradient can be measured with a pressure wire. Finally, check angiography is performed to confirm technical success which is usually defined as a residual stenosis of <50% by visual assessment. The patient is then carefully monitored post procedure with blood pressure, pulse and oxygen saturation measurements for a minimum period of 4 hours. In modern practice the majority of patients are already on antiplatelet therapy, but in rare cases where this is not already instigated, a minimum period of antiplatelet therapy with either aspirin or clopidogrel of 6 weeks is recommended. Non-invasive monitoring by either an experienced endovascular surgeon and his team, or a vascular anaesthetist, is mandatory usually with oxygen administration as required. Technical success 598 Renovascular disease rates are almost 100% with significant improvement in blood pressure control. These latter two are mediated by immunological responses and cardiovascular risk factors. The literature clearly supports better outcomes in terms of morbidity, mortality and renal graft survival using endovascular rather than open treatment confirming significant improvement in graft function and control of blood pressure. A recent single-centre retrospective review of a small number of patients reported significantly higher patency rates with drug-eluting stent in comparison to bare metal stents. Of these interventions, simple balloon angioplasty seems to have the highest recurrence rate with no significant difference between outcomes comparing simple balloon angioplasty versus cutting balloon angioplasty. There are little data to clearly define the best treatment, but drug-eluting stents and also covered stents may have the advantage in terms of reduced restenosis rate. There is some limited evidence that endovascular brachytherapy has promising results in the treatment of in-stent restenosis. A recent invited review updating intervention versus medical therapy from the Charleston Group attempted an analysis of all of these studies. For clinical outcome of renal function after intervention, most studies did not show a significant change in renal function in the majority, with deterioration in some but with improved renal function reported in 21% of 47 study treatment groups. An interesting and clinically relevant finding was that improvement or stabilization of renal function was not found in the more recent larger prospective randomized studies. A further relevant finding on the comparison of medical therapy with stent-only cohorts (these were in earlier studies) is that the stent-only group reported stable and improved renal function more commonly with a trend towards better blood pressure control, but neither difference reaching significance. The likely explanation for these findings is the marked improvement in Best Medical Therapy which has become established over these last 10­15 years.

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References

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