Seminars in vascular surgery
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Aortic disease is a significant pathology, as it represents the 12(th) leading cause of overall death. Aneurysms of the descending thoracic aorta pose a small but significant part of this pathology. Traditional open descending thoracic aortic aneurysm (TAA) repair continues to be performed despite relatively high morbidity and mortality rates. ⋯ Registry data of patients undergoing ETAR seems to mirror that of the aforementioned clinical trials and indicates acceptable morbidity and mortality profiles when compared to published open TAA repair results. Future prospective studies focused on patient selection likely will never be performed, as most believe the benefits of ETAR outweigh the lack of long term follow up data. This review will focus on repair of TAA, specifically clinical trial and registry data comparing open and endovascular repair.
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Acute limb ischemia is one of the most potentially devastating but treatable diseases faced by the vascular surgeon. It is crucial to identify the ischemic process early, as the outcomes of early intervention can lead to limb salvage, whereas late recognition places the patient at risk for limb loss and potential mortality. ⋯ Appropriate treatment and management of the limb are determined by the underlying cause of the ischemia. The authors will review the clinical features, angiographic findings, and strategies for management for these similar but distinct etiologies: acute embolic versus thrombotic limb ischemia.
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In acute lower limb ischemia, there are basically three management options: (1) clot removal by catheter-directed thrombolysis with or without percutaneous mechanical thrombectomy, (2) surgical thromboembolectomy followed by correction of underlying arterial lesions, and (3) anticoagulation with continued observation. Arterial embolic occlusion presents more abruptly and with more severe ischemia than arterial thrombosis, which occurs in narrowed arterial segments that have generally developed some degree of collateral circulation. The appropriate choice of treatment for acute limb ischemia depends to a great extent on the severity of the ischemia. ⋯ After clot removal, appropriate management of the responsible underlying lesion depends on its characteristics, best determined by vascular imaging. Staging the severity of ischemia according to clinical classification levels in the current reporting standards for lower extremity ischemia continues to serve as the basis for logical management decisions. This approach is outlined in algorithmic form and alternative pathways are discussed in this article.
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Statins belong to a class of drugs known to inhibit 3-hydroxy 3-methylglutaryl coenzyme A reductase, and block hepatic cholesterol synthesis. Since the initial statin was approved by the Food and Drug Administration in 1987, these agents quickly became the gold standard for treatment of hypercholesterolemia. Effective lipid-lowering has been found to improve the long-term prognosis of patients with coronary artery disease. ⋯ Preliminary work indicates that a similar benefit of statin use in reducing neurologic morbidity among patients undergoing carotid angioplasty and stent procedures. A number of the pleiotropic effects of statin medications may be responsible for these clinical observations. Further work is necessary to better elucidate these mechanisms, as well as to determine the optimal agents, dosing, and timing of drug administration among patients undergoing carotid interventions.
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Core training for surgeons in any surgical specialty should include education in the relevant basic science knowledge, training in fundamental diagnostic skills, the development of surgical technical skills and considerable experience in patient care. However, for a number of reasons it is no longer acceptable to guide such training based only on such broad goals, not the least of which is the advent of resident duty-hour limitations that make it unrealistic to expect residents to simply acquire, by random observation and participation, all of the important elements of their future practices. Rather, it is necessary to provide a curriculum of learning opportunities specifically structured to allow them to gain the requisite knowledge and skills. ⋯ Now evaluation must relate to specific educational objectives. This is all a daunting task currently being undertaken by vascular surgery program directors, albeit with input from the Residency Review Committee and the Vascular Surgery Board of the American Board of Surgery. Eventually, overall surgical curriculum will evolve to satisfy these educational ground rules, but currently it is very much a work in progress in most programs.