Chapter 109 - Infrainguinal disease surgical treatment

Question 1

Risk of severe clinical deterioration of a claudicant in 3-5 years

Answer 1

20%

Question 2

Risk of major amputation in claudicant in 3-5 years

Answer 2

5%

Question 3

European consensus document definition of CLI

Answer 3

1) persistent recurrent ischemic rest pain requiring opioid x 2 weeks 2) ankle pressure < 50 3) toe pressure < 30 4) ulceration or gangrene of foot/toes 5) absent pedal pulse in diabetic

Question 4

Wolfe and Wyatt on subcritical and critical CLI definition

Answer 4

Subcritical: rest pain Ankle pressure > 40 (27% limb alive at 1 year without surgery) Critical: rest pain/tissue loss ankle < 40 (5% limb alive at 1 year)

Question 5

Perioperative MI for LE arterial reconstruction

Answer 5

2-6.5%

Question 6

Venous conduit cutoff

Answer 6

2-3 mm - must dilate well 3 mm minimum

Question 7

Significant lesion based on pressure gradient

Answer 7

10 mmHg OR 15% drop after papaverine

Question 8

When should GSV bypass not be used as a patch simultaneously

Answer 8

1) thickened arterial wall 2) small donor artery 3) small vein conduit

Question 9

Linton’s technique

Answer 9

Vein patch first then bypass proximal anast on top of the patch

Question 10

Isolated popliteal target definition

Answer 10

1) 5 cm long popliteal 2) only geniculate collaterals

Question 11

Patency of isolated popliteal bypass target at 5 years

Answer 11

50% primary 74% secondary patency

Question 12

Bypass outflow principle in patient with tissue loss

Answer 12

inline flow with pulsatile foot

Question 13

When to choose pedal bypass over proximal peroneal

Answer 13

1) adequate conduit 2) frank tissue loss

Question 14

vein crossing over the proximal PFA

Answer 14

Lateral femoral circumflex vein

Question 15

Lateral approach to PFA key steps

Answer 15

1) incision in upper thigh lateral to sartorius 2) sartorius and SFA retracted medially 3) raphe between adductor longus and vastus medialis incised to expose PFA

Question 16

Branches of the profunda femoris artery

Answer 16

medial and lateral circumflex femoral artery 1st, 2nd, 3rd perforating branches

Question 17

Chance of needing contralateral GSV in future operation

Answer 17

20-25% no merit in saving unless already symptomatic

Question 18

Miller cuff

Answer 18

prosthetic to a circumferential cuff of vein

Question 19

Taylor patch

Answer 19

Patching open the hood with vein to make it bigger and more elastic

Question 20

St. Mary’s boot

Answer 20

the end of one end of the vein patch sews onto the side of another to create a cuff

Question 21

patency of heparin-bound dacron vs PTFE for above knee bypass at 3 year

Answer 21

55% vs 42% dacron better

Question 22

below knee bypass with PTFE +/- vein cuff 2 year patency

Answer 22

52% vs 29% vein patch/cuff works

Question 23

Human umbilical vein for bypass

Answer 23

Thicker and cumbersome to handle and risk of aneurysmal degeneration

Question 24

Distal AV fistula to increase bypass flow velocity

Answer 24

no clear evidence

Question 25

Heparin bonded PTFE pharmacodynamic

Answer 25

biologically active heparin up to 12 weeks effect in animals benefit up to 180 days not clear in humans

Question 26

Carmeda bioactive surface (CBAS)

Answer 26

heparin bonded material

Question 27

Solution to dilate venous conduit

Answer 27

1000 Units heparin and 60 mg of papaverine in 50-60 ml of autologous blood (better preserve graft endothelium) use saline instead for arm vein because thinner and harder to see leaks otherwise

Question 28

Types of valvulotomes

Answer 28

Mills - radial cutting Hall and LeMaitre - fixed diameter circumferential blades

Question 29

Completion assessment of the bypass

Answer 29

1) distal pulse palpation and Doppler flow +/- manual graft compression 2) completion arteriography 3) intraoperative duplex +/- papaverine 4) angioscope

Question 30

Post-bypass arteriography chance of correcting

Answer 30

8-27% patency increase from 72% to 100% in two weeks

Question 31

Completion duplex ultrasound chance for revision and downsides

Answer 31

12% no technician and equipment available

Question 32

Angioscope benefit

Answer 32

Assess arm vein conduits as well as for completion of valve lysis

Question 33

Factors associated with reduced graft patency

Answer 33

1) small conduit \< 3mm 2) poor run off 3) high outflow resistance 4) ESRD

Question 34

Define primary patency, assisted primary and secondary

Answer 34

Primary = patent continuously without any action Assisted primary = intervention but was never occluded (reflection of the surveillance and timely reintervention) Secondary = thrombosed but revived (reflection of surgeon persistence)

Question 35

Reversed vein vs in situ bypass in patency

Answer 35

same although for small vein \< 3mm, in situ seems to be better but not significant

Question 36

Comparison of primary patency for above knee fem-pop bypass conduit types

Answer 36

Comparable TABLE 109.3

Question 37

Comparison of primary/secondary patency for below knee fem-pop bypass conduit types

Answer 37

Vein much better than PTFE TABLE 109.4

Question 38

Comparison of patency for infrapopliteal grafts (tibial bypass)

Answer 38

Vein much better than arm vein and PTFE TABLE 109.5

Question 39

Pedal bypass results

Answer 39

TABLE 109.6

Question 40

BASIL key point

Answer 40

1) patients who live \> 2 years will benefit from bypass first strategy 2) vein better than prosthetic for CLTI 3) angioplasty then bypass vs bypass, primary bypass better for amputation free survival

Question 41

Treatment for WIfI clinical stage 4 patients

Answer 41

Open bypass

Question 42

Factors that increase the risk of graft failure

Answer 42

1) impaired ambulatory status at presentation 2) DM 3) ESRD 4) gangrene 5) prior vascular intervention combination worst

Question 43

FINNVASC score system

Answer 43

1) DM 2) foot gangrene 3) CAD 4) urgent operation risk on scale of 1-4 based on sum of all points externally validated

Question 44

PREVENT III prediction model

Answer 44

1) ESRD HD 4 points 2) tissue loss 3 points 3) age \> 75 2 points 4) CAD 1 point low risk \< 3 pt medium 4-7 high \> 8 externally validated

Question 45

BASIL stratification system

Answer 45

1) tissue loss 2) BMI 3) serum creatinine 4) Bollinger score 5) age 6) smoking 7) CAD 8) ankle pressure complex model not externally validated

Question 46

PREVENT III complication rates

Answer 46

death 2.7% MI 4.7% major amputation 1.8% graft occlusion 5.2% major wound complication 4.8% graft hemorrhage 0.4% Late complications 1) lymphedema 2) graft infection 3) graft anuerysm 4) graft stenosis

Question 47

Rate of graft threatening stenosis in 2 years from vein grafts

Answer 47

1/3

Question 48

Signs of a threatened graft

Answer 48

1) PSV \> 300 2) velocity ratio \> 3.5 - 4 3) PSV \< 45 4) drop in ABI \> 0.15

Question 49

Types of stenosis in vein graft follow up

Answer 49

Solitary stenosis 80% multiple focal lesions 15-20% Diffuse long segment narrowing 3-5%

Question 50

Principles of PTA of stenotic graft lesions after bypass

Answer 50

1) \> 6 month old grafts responds better 2) cutting balloon beneficial 3) no stenting 4) recurrence rate higher than open revision so need surveillance

Question 51

Surgical open revision of bypass stenosis

Answer 51

1) patch 2) interposition bypass 3) reciting proximal anast 4) jump graft