1. Out of the frying pan & into the fire
Dr Duncan Anderson
Vascular Surgeon

2. The frying pan
Traditionally the surgeon has been based in the operating theatre
Preoperative angiography was routinely performed by the radiologist

3. Case 1: Critical limb ischaemia
61 year old male
Non-healing left ankle ulcer for 9 months
Risk factors: heavy smoker, hypertension & hypercholestrolaemia
Only left femoral pulse
Ankle brachial index: 0.46

4. Case 1: Critical limb ischaemia
Catheter directed angiogram in the cathlab
Left femorodistal bypass to the posterior tibial artery
Composite graft of 6mm ring-reinforced PTFE & reversed saphenous vein

5. Case 1: Critical limb ischaemia
Who should be referred to a vascular surgeon?
And which special investigations should be performed prior to referral?

6. Who should be referred?
Any patient with claudication, rest pain, ulceration >2 weeks duration or gangrene
All patients with ankle brachial index <0.9
Any diabetic, chronic renal failure patient or heavy smoker with absent pedal pulses

7. Which special investigation?
Ankle brachial index (ABI) only
ABI manage vascular risk factors
ABI safely apply compression bandaging for venous stasis ulceration
No arterial duplex doppler ultrasound
No CT angiography
No MR angiography
No cathlab angiography

8. The fire
Vascular surgeons now perform the duplex doppler ultrasound & catheter directed angiography
Cathlab
Hybrid theatre
Offers a more goal directed therapy

9. Case 2: Complex varicose veins
36 year old female
Recurrent bilateral varicose veins
Vein surgery in 2005
Pelvic congestion syndrome
Menorrhagia
Dyspareunia
Dysmenorrhoea

10. Case 2: Suspect pelvic /ovarian vein reflux Recurrent varicose veins
Atypical varicose veins
Extensive groin varicosities
Vulvae varicosities
Pelvic congestion syndrome

11. Case 2: Complex varicose veins
CT venography
Not a routine special investigation (timing critical)
Catheter directed venography

12. Case 2: Complex varicose veins
Traditionally vein ligation & stripping
Endovenous laser or radiofrequency (VNUS) ablation
No groin wound
No thigh bruising
Less postoperative pain
Earlier mobilization

13. VNUS ablation Radiofrequency ablation Cathlab or rooms
Ultrasound-guided
Tumescence infiltration
Immediate ambulation

14. VNUS ablation Tumescence infiltration Local anaesthesia
Facilitates ablation by vein compression
Reduces risk of deep vein thrombosis
Creates “heat sink” to protect surrounding tissue

15. VNUS ablation Less pain & less bruising than laser ablation
Who should be referred to a vascular surgeon?

16. Who should be referred? Atypical distribution of varicose veins
Recurrent varicose vein
Associated chronic venous insufficiency (venous stasis dermatitis or venous ulcer)
Suspicion of pelvic/ovarian vein reflux
VNUS ablation for better cosmetic result, less pain & immediate mobilization

17. Case 3: False aneurysm 49 year old female
Painful swelling right groin 2 weeks after cathlab
BMI 40.4
Large false aneurysm flush with common femoral artery (no neck)

18. Case 3: False aneurysm Direct surgical approach Burst on skin incision
Direct digital control of 2cm defect in common femoral artery
Total of 4 unit blood transfusion

19. Case 3: False aneurysm Proximal control digitally through pelvis
Repaired with vein patch
Discharged after 6 days
High risk of wound & graft sepsis

20. Case 3: False aneurysm Negative surgical aspects
Additional open surgical procedure
Risk of anaesthesia
Prolonged hospital stay
Postoperative pain
High risk of wound & graft sepsis
Difficult mobilization

21. Case 4: False aneurysm 74 year old female
Painful right groin swelling 1 day after cathlab
BMI 32.2
Dropped haemoglobin from 13g% to 9g%

22. Case 4: False aneurysm Long & narrow neck
Ultrasound-guided thrombin injection

23. Case 4: False aneurysm

24. Case 4: False aneurysm
Angioplasty balloon to arrest flow within aneurysm
Thrombin (factor IIa) converts fibrinogen to fibrin
Discharged within 48hrs

25. “If all that you have is a hammer, then all that you’ll see are nails”
VASCULAR SURGEON
UROLOGIST
ANAESTHETIST