Vascular Surgery

666 Pages·2007·35.448 MB·English

by  Panagiotis E. Balas MD (auth.), Christos D. Liapis MD, FACS, FRCS, Klaus Balzer MD, Fabrizio Benedetti-Valentini MD, José Fernandes e Fernandes MD, PhD (eds.)

European Manual of Medicine Vascular Surgery
C. D.Liapis
Chief Editor
K.Balzer,F.Benedetti-Valentini,
J.FernandeseFernandes
Editors
Editors C. D. Liapis,
K. Balzer,
F. Benedetti-Valentini,
J. Fernandes e Fernandes
Vascular Surgery
With385Figuresand58Tables
123
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
Springer Berlin Heidelberg NewYork
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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
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.
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.
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.
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
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