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 Complications of Vascular Therapy

Dennis F. Bandyk , M.D., Jeffrey L. Ballard, M.D., Calvin B. Ernst, M.D.

Includes:

  • Pseudoaneurysms
  • Aortoenteric Fistulae/Erosions
  • Vascular Graft Infections
  • Colon Ischemia after Aortic Surgery
  • Chronic Perigraft Seromas
  • Occluded Prosthetic Grafts
  • Prosthetic Graft Dilation

I. Anatomy and Pathophysiology

1. To recognize the factors involved in loss of arterial wall and anastomotic tensile strength resulting in the development of pseudoaneurysms .

2. To define the incidence and mechanisms which led to the development of secondary aortoenteric fistulae and erosions.

3. To understand the multiple etiologic factors associated with increased risk of infection following arterial surgery, including biomaterial implantation, host immune factors, concomitant medical conditions, nature and magnitude of bacterial contamination, and wound healing complications.

4. To understand virulence factors of gram-positive and gram-negative microorganisms involved in vascular graft infections.

5. To understand mechanisms involved in bacterial contact, adherence, and colonization of prosthetic graft material.

6. To understand the etiologies causing absence of graft incorporation and perigraft fluid collections including infection, seroma , hematoma , and lymphocele .

7. To define the normal arterial circulation of the colon and anatomic variations produced by abdominal aneurysm repair and prior colectomy .

8. To understand the etiologies causing failure of graft incorporation and perigraft fluid collections including infection, seroma , hematoma , and lymphocele .

9. To recognize anatomic and hemodynamic conditions which can result in graft occlusion including myointimal hyperplasia, atherosclerotic disease progression, anastomotic false aneurysm formation, graft entrapment, low flow, thromboembolism , hypercoagulable states, and infections.

10. To understande the etiologic differences between immediate and late graft occlusions.

11. To define the incidence and mechanisms of prosthetic graft dilatation.

12. To understand the expected incidence and etiologies of wound healing complications including hematoma , infection, and lymphocele .

13. To recognize non-vascular complications associated with arterial therapy including cardiac ischemia, renal failure, and neurologic deficits.

14. To understand the normal arterial circulation of the spinal chord and the pathophysiology of paraplegia caused by spinal chord ischemia.

II. Diagnostic Evaluation

Pseudoaneuryms

1. To recognize the clinical manifestations of pseudoaneurysm following arteriography , percutaneous transluminal angioplasty, and bypass grafting.

2. To define the appropriate diagnostic evaluation of pseudoaneurysm including the use of duplex ultrasound, computed tomography, magnetic resonance imaging, and arteriography .

3. To recognize the operative findings of infected anastomotic false aneurysm.

Aortoenteric Fistulae/Erosions

1. To understand characteristic symptoms and signs of secondary aortoenteric fistula/erosion including prior aortic graft implantation, herald gastrointestinal bleeding, fever, and concomitant anastomotic false aneurysm.

2. To define the appropriate diagnostic evaluation of suspected secondary aorto - or graft-enteric fistula including upper endoscopy , anatomic imaging techniques (CT, MRI, arteriography ), and radionucleide functional scans.

3. To understand the role of operative graft exploration in patients with recurrent GI bleeding and normal GI endoscopy .

Vascular Graft Infections

1. To define the epidemiology of prosthetic graft infection.

2. To understand the characteristic signs and temporal presentation of acute versus late-appearing graft infections including sepsis, GI or perigraft bleeding, fever, malaise, false aneurysm, abdominal, back, or groin pain.

3. To understand the usefulness of various microbiologic culture (agar media, broth media) and recovery (swap culture, biomaterial culture, CT-directed aspiration) techniques in the diagnosis or confirmation of graft infection.

4. To understand the parameters of serologic testing that support the clinical diagnosis of vascular graft infection.

5. To define the appropriate diagnostic evaluation of suspected graft infection including microorganism recovery techniques, functional and anatomic graft imaging, and arteriography .

Colon Ischemia after Aortic Surgery

1. To understand the characteristic initial signs and symptoms suggestive of colon ischemia

2. To define pre- post-operative clinical conditions that may predispose to colon ischemia after after surgery including visceral occlusive disease (meandering mesenteric artery), prior color surgery, ligation of inferior mesenteric artery, ruptured abdominal aortic aneurysm, postoperative shock.

3. To understand the usefulness of Doppler ultrasound and photoplythesmography in the operative diagnosis of colon ischemia.

4. To define the appropriate diagnostic evaluation for suspected colon ischemia following aortic surgery including the use of rigid and flexible sigmoidoscopy , colonoscopy, and operative exploration.

5. To describe the endoscopic features of the severe and mild (reversible) forms colon ischemia after aortic surgery.

Occluded Prosthetic Grafts

1. To recognize the symptoms and signs of limb ischemia associated with graft thrombosis.

2. To understand the role and the interpretation of noninvasive vascular testing techniques used for the diagnosis of graft thrombosis including Doppler-derived limb blood pressure measurements, velocity waveform analysis, pulse volume recordings, and duplex scanning, .

3. To define the appropriate diagnostic evaluation of graft occlusion based on severity of limb ischemia.

4. To describe the angiographic features of graft occlusion which indicate embolic versus thrombotic occlusion, and the potential for catheter-directed thrombolysis as a treatment option.

Perigraft Seroma and Graft Dilatation

1. To define the clinical presentation of perigraft seroma and graft dilatation including symptoms, signs, and postoperative appearance time.

2. To understand the usefulness imaging techniques (ultrasound, CT, MRI, arteriography ) in the diagnosis of etiologic factors associated with failure or graft incorporation.

3. To describe the features of aspirated perigraft fluid which distinguish between chronic perigraft seroma and low-grade graft infection caused by S. epidermidis .

4. To understand the graft types associated with dilatation.

Wound Complications

1. To define the incidence and clinical manifestations associated with wound hematoma , infection, lymphocele , and dermal necrosis following arterial surgery.

2. To define the classification of wound infection following arterial bypass grafting.

3. To define the essentials of diagnosis to distinguish infectious from non-infectious wound complications.

Non-Vascular Complications

1. To understand the clinical symptoms and signs, and ECG features of cardiac ischemic.

2. To define the parameters of serologic and urine testing that characterize acute renal failure.

3. To understand the clinical symptoms and signs of neurologic deficit associated with spinal chord ischemia, injury to peripheral nerves, and cauda equina syndromes.

4. To define the appropriate evaluation of paraplegia following aortic surgery.

III . Treatment

Pseudoaneurysm

1. To define the anatomic features of false aneurysms which should be repaired.

2. To understand techniques for surgical exposure and proximal control of aortic, femoral, and other peripheral artery false aneurysms, including the use of balloon-tipped catheters to prevent backbleeding .

3. To define the role of duplex-guided ultrasound for the treatment of common femoral artery pseudoaneurysms following diagnostic arteriography or percutaneous endovascular procedures.

4. To understand the role of interposition grafting to normal artery wall in the treatment anastomotic false aneurysm.

Aortoenteric Fistulae/Erosions

1. To understand the role of staged-remote versus immediate-sequential bypass in treatment of aorto -enteric fistula based on severity of GI bleeding and degree of systemic sepsis.

2. To be familiar with surgical techniques involved in ex-situ bypass, total and partial graft excision, restoration of GI tract continuity, and in situ graft replacement using autologous venousgraft , endarterectomized arteries, allograft, and antibiotic-bonded vascular prostheses.

3. To be familiar with surgical techniques of aortic ligation including treatment or aortic sepsis involving the renal or visceral arteries.

4. To define the nature and duration of antibiotic therapy associated with treatment of secondary graft-enteric fistulae/erosions.

5. To define the follow-up of patients treated or aortoenteric fistula/erosion.

Vascular Graft Infections

1. To understand the role local treatment and other graft preservation techniques, including muscle flap coverage, in the treatment of exposed arterial grafts and graft infections without anastomotic involvement.

2. To understand the usefulness of in situ graft replacement techniques using autologous , allograft, and vascular prosthetic grafts in selected patients with vascular graft infections, including selection of treatment method based on clinical manifestations, microbiology, and operative findings.

3. To be familiar with antibiotic therapy based on susceptibility testing in the treatment of arterial graft infections.

4. To be familiar with surgical techniques for excision and ex-situ bypass of infected aortic, peripheral, and carotid arterial reconstructions/bypass grafts.

5. To understand the role of graft excision and arterial ligation in patients with graft infection and adequate collateral circulation.

6. To be familiar with surgical techniques for the treatment of aortic stump sepsis or disruption.

7. To define the expected outcome of patients treated for aortic, infrainguinal , or carotid graft infections.

Colon Ischemia after Aortic Surgery

1. To be familiar with criteria for IMA re- implatation during aortic surgery.

2. To understand the role and technique of colon resection in treatment of severe ischemia.

3. To define the treatment and follow-up of mild colon ischemia following aortic surgery.

Occluded Prosthetic Grafts

1. To be familiar with surgical techniques useful in the treatment of immediate versus late graft occlusions.

2. To define the role of thrombolysis versus surgical intervention for graft occlusion/thrombosis.

3. To define the indications for graft thrombectomy and revision versus graft replacement.

4. To define the role of endovascular techniques ( angioscopy , PTA, stent placement) as adjuncts to graft revision procedures.

5. To be familiar with extra-anatomic bypass grafting techniques in treatment of aortofemoral graft limb occlusion.

6. To understand the role of anti- thrombotic therapy in treatment of graft thrombosis.

Perigraft Seroma and Graft Dilatation

1. To be familiar with graft replacement techniques as treatment for perigraft seroma and graft structural failure.

2. To understand the importance of microbiologic recovery techniques, including broth culture of graft material, to exclude a biofilm infection.

3. To define the surveillance of prosthetic grafts following implantation to diagnose dilatation, failure of graft incorporation/healing, and anastomotic false aneurysm.

Wound Complications

1. To understand the role of prophylactic antibiotics in the prevention wound and graft infections.

2. To understand the standard surgical principles used to treat wound necrosis, hemaatoma , and infection.

3. To be familiar with non-surgical and surgical techniques useful in the treatment of lymph fistula, lymphocele , and postoperative lymphoedema .

Nonvascular Complications (Cardiac, Renal, Neurologic)

1. To understand the role of pre-operative testing, intra-operative monitoring, and post-operative measures to prevent cardiac ischemia.

2. To be familiar with renal preservation techniques associated with aortic and renal surgery.

3. To be familiar with techniques to improve spinal chord perfusion during aortic surgery.

References

1. Complications in Vascular Surgery. Bernhard VM and Towne JB ( eds ), St Louis : Quality Medical Publishing, 1991.

2. Management of Infected Arterial Grafts. Calligaro KD and Veith FJ ( eds ), St Louis : Quality Medical Publishing, 1994.

3. Brewster DC, et al. Reoperation for aortofemoral graft limb occlusion: Optimal methods and long - term results. J Vasc Surg 1987 ;5:363 .

4. Reilly LM et al. Improved management of aortic graft infections: the influence of operation sequence and staging. J Vasc Surg 1987 ;5:421 .

5. Hobson RW, et al. Assessment of colon ischemia during aortic surgery by Doppler ultrasound. J Surg Res 1976 ;20:231 .

6. Paul SD, Eagle KA. Modalities for assessment of cardiac risk in vascular surgery. In Callow AD and Ernst CB ( eds ), Stanford, CN: Vascular Surgery: Theory and Practice, 1995, p 783.

7. Safi HJH, et al. Neurological deficit in high risk patients with thoracoabdominal aortic aneurysms: the role of cerebral spinal fluid drainage and distal aortic perfusion. J Vasc Surg 1994; 19:236.

8. Bergamini TM, et al. Infection of vascular prostheses caused by bacterial biofilms . J Vasc Surg 1988; 7 ;21 .

9. Kuestner LM, et al. Secondary aortoenteric fistula: contemporary outcome using extra - anatomic bypass and infected graft excision. J Vasc Surg 1995; 21:184.

10. Berlauk JF, et al. Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. Ann Surg 1991; 214:289.

11. Blumberg RM, et al. Perigraft seromas complicating arterial grafts. J Crdiovasc Surg 1983; 24:372.

12. Watanabe T, et al. Failure of Dacron arterial prostheses caused by structural defects. J Cardiovasc Surg 1983; 24:95.

13. Schellack J, et al. Femoral anastomotic aneurysms: a continuing challenge. J Vasc Surg 1987; 6:308.

Posted June 2010