Seminars in Vascular Surgery最新文献

The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.

Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Despite advances in open and endovascular management of trauma, vascular injuries remain a source of devastating outcomes. This narrative review of the literature between 2018 and 2023 explored recent advances in abdominopelvic and lower extremity vascular injury management. New conduit choices, use of temporary intravascular shunts, and advances in endovascular management of vascular trauma were reviewed. Although endovascular techniques are being applied more frequently, there is a paucity of reporting on long-term outcomes. Open surgery is durable and effective and remains the gold standard for repairing most abdominal, pelvic, and lower extremity vascular injuries. Vascular reconstruction conduit options are currently limited to the autologous vein, prosthetic grafts, and cryopreserved cadaveric xenografts; each type has its own application challenges. The temporary intravascular shunts can be used to restore early perfusion to ischemic limbs and increase the chances of limb salvage, or when transfer of care is needed. Resuscitative balloon occlusion of the inferior vena cava has been a research-heavy topic to investigate the possible implications in patients with trauma. Early diagnosis, appropriate use of technology, and time-sensitive management can make all the difference in the lives of patients with vascular trauma. Endovascular management of vascular trauma is evolving and gaining wider acceptance for treatment of vascular injuries. Computed tomography angiography is widely available and is the current gold standard for diagnosis. Autologous vein remains the gold standard for conduit with the future promise of new innovative conduits. Vascular surgeons have an important role in vascular trauma management.

Symptomatic carotid stenosis and carotid dissection are acute conditions of extracranial cerebrovascular vessels determining transient ischemic attack or stroke. Medical, surgical, or endovascular management are different options to treat these pathologies. This narrative review focused on the management, from symptoms to treatment, of the acute conditions of extracranial cerebrovascular vessels, including post–carotid revascularization stroke. Symptomatic carotid stenosis (> 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria) with transient ischemic attack or stroke benefits from carotid revascularization—primarily with carotid endarterectomy associated with medical therapy—within 2 weeks from symptom onset to reduce the risk of stroke recurrence. Different from acute extracranial carotid dissection, medical management with antiplatelet or anticoagulant therapy can prevent new neurologic ischemic events, considering stenting only in case of symptom recurrence. Stroke after carotid revascularization can be associated with the following etiologies: carotid manipulation, plaque fragmentation, or clamping ischemia. Medical or surgical management is therefore influenced by the cause and timing of the neurologic events after carotid revascularization. Acute conditions of the extracranial cerebrovascular vessels include a heterogeneous group of pathologies and correct management can reduce symptom recurrence substantially.

Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage (“time is tissue”). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.

Vascular specialists remain in high demand in current practice and commonly oversee care delivery for a variety of clinical emergencies. Accordingly, the contemporary vascular surgeon must be facile with treating a spectrum of problems, including a complex, heterogeneous group of acute arteriovenous thromboembolic and bleeding diatheses. It has been documented previously that there are substantial current workforce limitations placing constraints on vascular surgical care provision. Moreover, with the aging at-risk population, there remains a considerable national urgency to improve timely diagnoses, specialty consultation, and appropriate transfer of patients to centers of excellence capable of providing a comprehensive compendium of emergency vascular services. Clinical decision aids, simulation training, and regionalization of nonelective vascular problems are all strategies that have been increasingly recognized to address these service gaps. Notably, clinical research in vascular surgery has traditionally focused on identification of patient- and procedure-related factors that influence outcomes by using resource-intensive causal inference methodology. By comparison, large data sets have only more recently been recognized to be a valuable tool that can provide heuristic algorithms to address more complex health care problems. Such data can be manipulated to generate clinical risk scores and decision aids, as well as robust outcome descriptions, which stand to inform stakeholders regarding best practice. The purpose of this review was to provide a robust overview of the lessons derived from the application of big data, risk prediction, and simulation in the management of vascular emergencies.

The most important descending thoracic aortic (DTA) pathologies are aneurysms, dissections, and traumatic injuries. In acute settings, these conditions can constitute a significant risk of bleeding or ischemia of vital organs, resulting in a fatal outcome. Morbidity and mortality associated with aortic pathologies remain significant, despite improvements in medical therapy and endovascular techniques. In this narrative review, we present an overview of the transitions in the management of these pathologies and discuss current challenges and future perspectives. Diagnostic challenges include differentiating between thoracic aortic pathologies and cardiac diseases. Efforts have been made to identify a blood test that can rapidly differentiate these pathologies. Computed tomography is the cornerstone of diagnosing thoracic aortic emergencies. Our understanding of DTA pathologies has improved substantially due to the significant advancement in imaging modalities in the last 2 decades. On the basis of this understanding, the treatment of these pathologies has been revolutionized. Unfortunately, robust evidence from prospective and randomized studies is still lacking for the management of most DTA diseases. Medical management plays a crucial role in achieving early stability during these life-threatening emergencies. This includes intensive care monitoring, heart rate and blood pressure control, and considering permissive hypotension for patients presenting with ruptured aneurysms. Over the years, surgical management of DTA pathologies changed from open repair to endovascular repair with dedicated stent-grafts. Techniques in both spectrums have improved substantially.

Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.