Showing posts with label Vascularsurgery. Show all posts
Showing posts with label Vascularsurgery. Show all posts

Thursday, 27 April 2017

Twitter Conference: Charing Cross Vascular Symposium #cx2017 Day Two

Since my paper is being presented and I am unable to be there, I will be 'attending' the Charing Cross Vascular Symposium through the wonderful medium of twitter. Following the hashtag #CX2017  I hope to catch as much as possible here on my blog. This is what I caught from Day 2:

Again the organisers continued with there fantastic ask the audience sections
And the results were interesting...












thanks to the twitter warriors: @cookEVAR @claudicant @perealtes @ozvascdoc @veryanmed1 @torbjornlundh @cxsymposium @vascularMD

Wednesday, 26 April 2017

Twitter Conference: Charing Cross Vascular Symposium #cx2017 Day One

Since my paper is being presented and I am unable to be there, I will be 'attending' the Charing Cross Vascular Symposium through the wonderful medium of twitter. Following the hashtag #CX2017  I hope to catch as much as possible here on my blog.
The first day was all about peripheral artery disease and the audience were asked some interesting questions regarding the their views on PAD, here are the results:

Dr Hauton alongside Dr Mastracci with her wonderful video in my last post addressed concerns on radition exposure, pointing out that 1 DSA image is roughly equal to 500 fluoro images:

 Mr Weinberg posted the following, pointing out that PAD patients receive better outcomes when combining exercise with revascularisation (linkhere):

Lucky man Dittmar Bockler loves his DynaCT:

What about smoking cessation in vascular patients, try try again:


 Dr Anders Wanhainen on the need for a disease specific solution for type B dissection.

Currently watching closely the twitter-web today, following todays focus on Abdominal aortic aneurysms... watch this space. 
Thanks to @PereAltes @Angiologist @CXsymposium @CookEVAR @ozvascdoc 

Sunday, 2 April 2017

Michael Debakey: The Janitor and I, Saving Lives Together


There are already milions of blog posts all over the internet about the many wonderful things Michael Debakey did and invented. I love reading stories about him, besides being the father of cardiothoracic and vascular surgery and prolific surgeon he was also a down to earth and wonderful man it seems. below is my favourite story of his;

In one particular encounter, DeBakey began chatting with an elderly janitor who was sweeping the floor. DeBakey asked the man about his wife and children. He told the older man, obviously not for the first time, that the hospital couldn’t function without the janitor because germs would spread, increasing the chances of infection in the hospital. Later in the day, our colleague tracked down the janitor and asked him, “What exactly do you do? Tell me about your job.” With pride, the janitor replied: “Dr. DeBakey and I? We save lives together.”
He’s right. After all, consider what would happen to our healthcare systems if the cleaning crews went on strike. DeBakey understood that showing the janitor exactly how he contributes to a larger, more heroic cause is crucial. This creates a powerful dynamic. Realizing that he is working toward a worthy goal, the janitor’s perceptions about his work changed. It had new meaning and his enthusiasm for the job was rejuvenated.
Source: http://www.freibergs.com/resources/articles/leadership/10-things-we-can-learn-from-the-worlds-greatest-surgeon/  (its a great post and worth a read, it certainly makes a young doctor feel inspired).

Tuesday, 22 March 2016

Pseudoaneurysms

Interesting case in the emergency theatres today. 40yr old male with a large hematoma in the left thigh. One week ago he underwent a cardiac procedure that required the use of an intra-aortic balloon pump.
Have an idea yet?
Insertion of an IABP is through a catheter in the femoral artery, if this puncture is misplaced or compression afterwards to close the wound is insufficient then the artery can continue bleeding into the thigh and form a pseudoaneurysm.
This chap had a pseudoaneurysm for exactly that reason, in fact you could see on doppler-ultrasound the hole was in the superficial femoral artery. The superficial femoral artery is a common origin of pseudoaneurysms because when you apply compression to the leg after cath lab or interventional radiology procedures for hemostasis, the femoral bone is not behind (as it would be for a standard common femoral artery puncture), so compression is ineffective.

What is a pseudoaneurysm?
Usually the result of injury to an arterial wall a pseudoaneurysm is an aneurysm lacking all three normal elements of an arterial wall. Pulsatile flow from the ruptured artery dissects the neighbouring tissues and forms a false lumen or sac containing the hematoma.

Risk factors: are any intra-arterial puncturing procedure, which increases in proportion to the size of catheter (larger catheters having higher rates of pseudoaneurysm formation). The risk is increased when the puncture site is not the common femoral artery eg. external iliac, superficial femoral and profunda femoral arteries.

How do you diagnose a pseudoaneurysm?
Most common presentation is pain and swelling in the groin area. Often the pain is disproportionate to the pain expected from the procedure. Large hematomas can compress neighbouring nerves and veins, and even cause skin necrosis.
Conduct peripheral pulse examination, ankle-brachial index and ultrasound scan of the area.
The best intial diagnostic test is a duplex ultrasound scan (7mhz linear probe). you can find and measure the diameter of the pseudoaneurysm neck.
If a doppler US scan cannot be performed the next step is a CT scan with contrast.

Management and treatment
So after support and resuscitation (a ruptured pseudoaneurysm can lead to catastrophic bleeding).
there are four main treatments:

  1. Observation: for small pseudoaneurysms, less than 2cm. these will often spontaneously heal within a few weeks. keep monitoring with regular ultrasound scans. disadvantages include prolonged hospital stays and restricted activity.
  2. US-guided compression: very variable success rates, the compression has to be maintained for at least 15minutes, aim for 20minutes. the probe can be used to target the pseudoaneuryms neck accurately. disadvantages include the fact that it not tolerated well and can be challenging. 
  3. Percutaneous thrombin injection: guided by US thrombin is injected into the pseudoaneurysm cavity for immediate thrombosis. the real risk of embolism limits the procedure to pseudoaneurysms with a neck smaller than 4mm. often a well tolerated and successful procedure it does require anticoagulation therapy. 
  4. Open surgical repair: Best for patients with complications or contraindicated to non-surgical management. open surgical repair allows direct visualization and control of the bleeding with suturing of the puncture site or patch angioplasty. hematoma can be evacuated and compression symtoms relieved. there are of course risks with any surgical procedure with  wound infction, lymphocele, radiculopathy and myocardial infarction topping the list. (make sure you check both sides of the artery).
So our patient had intially complained of a small thigh hematoma a few days after the cardiac procedure, he was infact in ITU with respiratory problems (complicated history). The surgeon had a look and since it was small and also considering the state of the patient, opted for the observation approach. so four/five days later the hematoma had expanded rapidly and considering the blood loss and size, open surgical repair was the best option. Operation went well, chap is doing fine. the hole was easily controlled with a controlled stitch and the hematoma evacuated from the anterior thigh and inguinal area. 

(pseudoaneurysm after arterial puncture to the superficial femoral artery)

Thursday, 10 March 2016

What vessel arises from abdominal aorta and supplies an organ in the pelvis? (and isnt the inferior mesenteric artery)

I was scrubbed into a vascular surgery operation the other day, a standard aneurysmectomy when the consultant asked me "whats this vessel?". I had no flipping clue, the aorta was exposed and this mysterious vessel seemed to branch from just below the renal arteries and travel down into the pelvis.
It was one of the paired Gonadal arteries! (AKA testicular arteries or ovarian arteries)

The arteries supplying the testicles or ovaries arise from the abdominal aorta at around the L2 level. This is because of the embryological descent of the gonads from the abdominal cavity to their rightful position in the pelvis or scrotum (this process starts at the 3rd month of prgenancy and ends at the end of pregnancy). 
There are a few anatomical variants where the gonandal artery arises from the renal artery or slips behind the inferior vena cava before descending, it may even originate higher than the L2 area. 
So dont forget the Gonadal arteries!


Wednesday, 3 February 2016

Bézier curves and Raster vs Vector images

So I was really lucky today to have a tutorial from the head of vascular surgery about some basic imaging concepts.

Endovascular and vascular surgery requires careful planning beforehand using mainly CT scans. Since the aorta and many vessels can have tortuous paths, it can be difficult to to appreciate the true path of the vessel using only the traditional axial views or even sagittal/frontal reconstructions offered by the hopsital pacs system.

Horos is a free open source software (for macs only at the moment)  for medical imaging viewing. Pretty damn neat, download it and get involved!
Using an open source software like Horos or Osiris (another), you can do what's called multiplanar reconstructions which can enable you to take a slice of the body from any angle.
An incredibly valuable tool in surgical planning.
(as a medical student its actually worth playing around on)

Bézier curve
Is a curve that put simply can be generated from three simple points. You may have noticed it from powerpoint or photoshop programmes.
Youtube clip illustrating bézier curves
The maths is utilized when you trace a path aong the aorta in simply points. If you put the points in the centre of the lumen, the curve of the aorta can traced and you can generate an image that perfectly follows the curvature of the aorta.

The two kinds of images
Raster and vectorial images
Raster or bitmap images are your classic PC jpeg photo file. Every pixel colour is coded in the file and the location of each pixel is recorded. So a completely black square will still have lots of information coded as each pixel reports its location and colour (black).
Vectorial images are different, the file will simply state the size of square and all black for example. If you were to place a white circle over one corner of the image, the angle of the curvature would be coded by Bézier curve maths and then the colour behind simply coded white. With a vector/vectorial image, there is a lot less information to be coded and of course the file is significantly smaller.
CT scan slices are raster images. 
A raster image is of course better for images with lots of small details.
Helpful webpage

When using a CT scan to plan surgery pay attention to the thickness between slices. Optimal thickness is 0.2mm.

#CTscan #Vascularsurgery #Béziercurve #Imaging #MEDed #medicine