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ABSITE Review: Vascular, Part 2 (Podcast)
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ABSITE Review: Vascular, Part 2 (Podcast)
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>> Okay. And welcome back to another "Behind the Knife ABSITE Review". This is "Vascular, Part 2". Thank you guys for joining in with us. Today we have Jason Bingham, John McClellan, and myself, Kevin Kniery. We really appreciate everyone that is going on to iTunes and giving us a rating. It really helps. And then also subscribing to our podcast and signing up for a mailing list. We're putting a lot of work into this and it gives us a lot of gratification to see that you guys are liking it.
Don't be that one or two people that gave us a four-star review. If you're having trouble with your audio or accessing, please email me and I will help you guys make sure you have good audio quality and able to access it easily. >> And we can't reiterate that enough. I mean we put a lot of effort in this. We're not getting paid for this. We're doing this for you guys. So what really helps us out is if you go on and you give us a rating. Sign up for our mailing list.
Subscribe to the podcast. That's what, you know, keeps us going and allows us to keep doing this. >> Yep. So send all your technical difficulties to Kevin@behindtheknife.org. Jumping into "Vascular, Part 2". So, John, what is the most common splanchnic aneurysm? >> So most common one you find, and the one most commonly tested is the splanchnic aneurysm. >> And what patients are at highest risk for these splanchnic aneurysms? >> So pregnant patients are the ones you usually see questions on, and also patients with portal hypertension.
>> Great. Okay. So, John, what is the clinical presentation of a patient that presents with a ruptured splanchnic aneurysm? >> Yep. Like we talked about in a previous podcast, you'd have that double rupture. So you have a aneurysm that will rupture within the lesser sac. And then eventually, after time, you have a free intraperitoneal rupture after [inaudible] -- excuse me -- the lesser sac. >> Great. And so what are your criteria if you have a patient that comes in, a pregnant patient that has appendicitis or something, gets a CT scan and they note a splanchnic aneurysm on that CT scan?
What are your indications for an elective repair of the splanchnic aneurysm. >> So the bottom line for any pregnant patient is repair any splanchnic aneurysm. For anybody else, it's usually when it's greater than two centimeters. >> Great. And what are your go-to treatment options? >> So any pregnant patient who has a splanchnic aneurysm or patient, or any woman of childbearing age should have it repairs immediately. And then for anyone else, it's greater than two centimeters. >> The mortality once you have a splanchnic artery aneurysm rupture is like 75% so they're pretty strict criteria because of that.
So if you find it incidentally or they're not exsanguinating, you can do coil embolization. If the patient comes in with a rupture, you're going to do an exploratory laparotomy and a splenectomy to remove the splanchnic aneurysm. >> Okay. Just really briefly, Jason, what are the other sites that you see splanchnic aneurysms and what are your criteria to repair them? >> So other than your splanchnic aneurysms, you can see a hepatic or SMA aneurysms.
These are very, very rare. The treatment size is generally the same, two centimeters for these visceral aneurysms. And for these you generally need to resect and reconstruct. >> Right. And so it's important to note so that you are going to repair these same size criteria, two centimeters but you obviously can't just, for the most part, ligate your hepatic artery or ligate your SMA. You're going to have to resect and reconstruct these patients if that question does come up. Okay. So, John, on to iliac. A lot of times these are seen in association with aortic disease but we're talking about just incidentally found iliac artery aneurysms, what are your size criteria for these patients?
>> Yeah. These are relatively rare lesions that you want to repair them if they're symptomatic or if they have greater than three-and-a-half centimeters. And your endovascular repair is your best option here. >> Right. So as Dr. Aaronson said in the 2017 Vascular Abstract Review, if you're doing it with a aortic aneurysm, you'll generally repair these at around three centimeters. But if these are found isolated and you'll repair these at 3.5. And these can be very morbid due to their location.
And a deep in the pelvis trying to repair these so they can be quite difficult. So, John, what is your criteria for repairing femoral aneurysms? >> So the new cutoff, the previous ABSITE reviews said that two-and-a-half centimeter. >> So are you going to resect and place the inner position or are you going to do an exclusion and bypass? >> These patients you resect and place the inner position. >> Right. So, Jason, popliteal aneurysms, we talked about this briefly last year. What are these associated with and how do these present?
>> So the popliteal aneurysms are frequently associated with triple A's so about 50% of the time if you have a patient with a popliteal aneurysm, they're also going to have a triple A. So you need to image the abdomen if you diagnose a popliteal aneurysm. >> So are you worried about rupture in these patients? >> No. No. It's not rupture you're so much worried about as it is embolization. >> Right. So you have embolization or thrombosis is what you're most concerned about in these patients with popliteal aneurysm. And so, Jason, what is your size criteria for this?
>> So for asymptomatic it's two centimeters. And then any symptomatic patients would be elective for a repair. >> And then are there some other criteria that you would maybe consider repairing? >> So, yeah. If you have mural thrombus or it's doing anything that's going to affect the distal flow, so you have a poor runoff, those would also be indication for repair. >> Right. And so how about this patient, is it the same as the femoral aneurysm? Are you going to do a resection and inner position on these patients?
>> So, no. For these patients you want to do an exclusion and bypass. It's typically going to be the answer on a test. Anything that distal you're going to want to opt for a vein graft and avoid any prosthesis if you can. I know there are out there in the population or out there in the community there's some newer stents that are being used for these. But the standard treatment is bypass and exclusion and that's definitely going to be the answer on the boards.
>> Right. And the way I remember this is that you can do an exclusion and bypass with the patient in supine from a medial incision. If you truly want to do a good resection and inner position, it would be pretty hard to do from the medial approach given the course of the popliteal artery. So these patients you're going to just exclude it and bypass it. So you'll leave it there. The aneurysm will still be there but there will be no blood flow through it. So, John, we always get questions on these. You have the patient that has either renal hypertension or has carotid disease and they say on their CT angio they have beads of string appearance.
What is this, and how is this treated, and why is this something to know about? >> Yeah. That's essentially pathognomonic for fibromuscular dysplasia. It's most commonly found in the renal arteries, but like Kevin mentioned, you can also get it in the internal carotids as well. And you're treatment is balloon angioplasty is your first line. >> Right. And whichever place it is, the renals or the carotids, within two questions will get you to balloon angioplasty. And this is actually a good question that they can give you a picture for. So I would google, you know, angiographic findings of this because this is a classic one that you could be given an image and asked how you would treat it and they wouldn't tell you anything about the beads of a string sign.
Okay. So, Jason, we're just going to briefly cover triple A indications. What are the indications you're currently using when you're repairing triple A's? >> Okay. So properly repair triple A's, we'll start with the easy ones. So if they're symptomatic, they need treatment. It's infected, it needs treatment. The size cutoff for men, five-and-a-half centimeters going to like be my cutoff. It's going to be slightly smaller for females, five centimeters. And then you also want to look at the growth rate.
So if it grows greater than a centimeter in a one-year time period, that's another indication for repair. >> So, since you brought it up, what are the two most common organisms involved in mycotic aneurysms? >> So for mycotic aneurysm the classically the organism tied is salmonella and that used to be the answer for the most common. Now I believe the answer for the most common is going to be staph. But staph and salmonella are going to be the two most common organisms.
>> Great. And so mycoses is generally associated with fungi but not when we're talking about aneurysms. So, John, you're doing an aortic repair. You've sewed everything in and you're trying to decide do I reimplant this IMA? Do I add another 45 minutes to my procedure? What are the kind of criteria you're going to use to decide to reimplant that IMA? >> Yeah. So this is a intraoperative decision. You want to first look at your back pressure of your IMA.
Is it very good? Is it poor? Is it less than 40 millimeters of mercury? And also look at the colon as well. Does it appear dusky or did they have a history of previous colon surgery? >> Great. And then, Jason, why does previous colonic surgery, why is that an important question to ask your patients that are getting a triple A repair? >> So when you, you're going to disrupt, with debridement surgery you're going to disrupt your collateral flow so you're talking about your [inaudible], your marginal artery.
You may have disrupted that collateral flow that you otherwise would have. >> Right. And so if a patient has had previous colonic surgery, you're going to have a lower threshold to reimplant the IMA because they're going to have a higher risk of colonic ischemia. So now, since we're talking about preserving vessels, John, how about your internal iliac? Say you're doing an aortabifem, and you're trying to decide if you're going to preserve your internal iliacs, what are your decision making on that? >> I'll also ask you if you need to preserve your hypogastrics as well.
And you want to make sure you're assured of flow to at least one of them. >> Right. And so just remember, hypogastrics and internal iliacs are used interchangeably and you want to make sure you preserve blood flow to at least one of them. Otherwise there's a risk of buttock claudication and pelvic ischemia. So, Jason, you know, the ER calls you. They have a patient with a triple A of four centimeters. And, you know, you see a patient and you tell to follow up with me.
What study are you going to order for them on their follow-up in a year? >> So we're assuming this is an asymptomatic [inaudible] and an incidence we found four centimeter triple A, is that right? >> Yes. >> Okay. So for a asymptomatic patient with a four centimeter, I'm going to tell them to follow up with an annual duplex of the abdominal aorta. >> Exactly. Okay, John, I want to talk about a few complications of your triple A. This is, you know, almost more common than the questions of indications to treat is managing the complications.
A lot of times these involve general surgery. So you have a patient that had their triple A repaired and they're getting close to leaving the hospital but maybe kind of develop ascites. They have some abdominal distension that's not painful. You see it on, you know, you get a CT of their abdomen because you're concerned. And you see a fluid collection, you tap it, it's a milky fluid. What is this and how do you want to treat this? >> Yeah. After an open triple A, you can develop chyle ascites and the treatment is a low fat, high protein diet with the medium chain fatty acids supplementation.
And if that doesn't work, then you want to place the patient NPO and TPN. >> So wait. Why not a long chain fatty acid supplementation? >> Yeah. So your long chain fatty acids are absorbed through your chylomicrons into your lymphatic system where your medium chains are absorbed directly into the bloodstream. >> Right. And so they're absorbed directly into the portal system. So whether it's related to vascular or not, you're get a patient with some sort of chylous complication, these patients you're going to put on a low fat, high protein diet with medium chain fatty acid supplementation.
And that will, hopefully, allow their chylous leak to resolve. And, yeah. That's the treatment. So, Jason, so you're doing an open aortic repair, and you're clamping the aorta in the suprarenal position, and you have massive blood flow, blood loss behind your aorta. What is likely the reason for this? >> So first off, the left renal vein is subject to injury whenever you're dissecting in your suprarenal aorta, either whether it's in a [inaudible] position or whether it's a retroaortic.
But I think what you're going for is, you know, particularly if you have a retroaortic renal vein, you can injure it when you cross [inaudible] aorta. And that is a bad situation. >> Right. [Inaudible] hold to your inferior vena cava, you're butting this so you definitely want to be careful for the left renal vein, especially if it is anomalous in the retroaortic position. A little tidbit, we don't think we have a urology podcast but they're going to ask you the hilar vessels of the kidney, the answer is the renal vein, the renal artery, and then the pelvic collecting duct system.
So that is the normal arrangement. And the renal vein is normally anterior to the aorta but at times it can be retroaortic. Okay. I think we beat that into the ground. So, John, another dreaded situation, post-op day one, the patient develops, after a triple A repair endovascular open, abdominal pain, bloody diarrhea. What are you concerned about? >> Yeah. This is one of your more common things you might encounter in practice is that you may have ischemic colitis.
And you want to do a sigmoidoscopy to help diagnose this. And then the patient needs to be adequately resuscitated and you want to start IV antibiotics as well. The majority of these people will be managed non-operatively. However, like any type of generally surgery world, is if they develop peritonitis, sepsis, or they have a free perforation, or necrosis, then you need to have, take them to the operating room for a total abdominal colectomy and Hartmann's pouch. >> Yeah. And so, John, it's a lot harder to get the GI nurse to come down and set up the sigmoid scope, but I have a proctoscope in my clinic.
And I can just do the evaluation there of the rectum, and, you know, and tell them if they have this problem. Is that adequate? Is proctoscopy adequate? >> No. The proctoscope isn't adequate because you have good collateral flow from your middle and distal rectal arteries because they originate from the internal iliac, not from the IMA. So you really need a sigmoidoscopy to look at everything. >> Right. I've never seen that question but if I was writing questions in a few years, I'd probably ask that question.
So you need a sigmoidoscopy because the rectum has different blood flow from the internal iliacs and not the interior mesenteric artery. Okay, Jason. Your patient comes in with fevers, chills, and some abdominal pain, you know, three months after the aortic graft repair. What are you concerned about? How are you going to diagnose it? And what is your treatment for it? >> So it sounds like a graft infection.
So I would diagnose it with some labs, some cultures. I'd get some imaging, CT scan, potentially a white blood cell scan. And, yeah, that would be my approach to diagnosis. >> Great. And sometimes people will do a tap of these or something of the fluid collection around the aorta, but what is your treatment going to be? >> So if you confirm that you have a graft infection, you need a graft excision, first and foremost. You need source control. And then you need an extra anatomic bypass.
So either, for this patient, either an ax-bifem, or an ax-fem with a fem-fem bypass. >> Great. And so this is an important point to remember for no matter where in the body you have a bypass. If you have a fluid collection that is infected, on the ABSITE you are going to take down that graft and do a, somehow redo the bypass. You're never going to, you know, treat it with antibiotic beads.
You're never just going to drain it. You have to do the, it sometimes it seems really dramatic and there's no bleeding, there's nothing's going that bad. But this will rupture and this will create a pseudo aneurysm and rupture if you do not adequately treat this. >> And bypass through normal tissue. So the extra anatomic. So you can't simply take the graft out and put in a new one. You have to go through healthy tissue.
>> Exactly. Okay. So, John, you know, we have some fancy technology now. We're able to do the endovascular aortic repairs. What are the general criteria that you want to use on the ABSITE for patients that qualify for an abdominal endovascular repair? >> Yeah. So looking at here, your first part, the neck and the, just below your renals, you want a neck diameter at least of 32, or 3.2 centimeters. You want an angle less than 60 degrees.
And you want a length of at least one centimeter. If you're going down to the iliacs, you want to look at your landing zones. You want a iliac diameter of at least seven millimeters. And you also want a landing zone greater than one centimeter. >> Great. And so this is probably definitely going to be one question on your ABSITE. Just know the indications for [inaudible] and ones that, so the things that I've seen that are asked most commonly are the diameters being too small for the access vessel. So if they give you a five millimeter iliac, you're not going to be able to get the graft up there.
And that would be an indication for an open procedure. If they give you extremely angulated, or if they give you a short landing zone, less than a centimeter, these are patients that are going to need an open aortic abdominal repair. Okay, Jason, can you talk to me about the types of endoleaks there are? >> There's five types of endoleaks, really four relevant ones. So there's type one endoleaks which are either, there's type one A versus type one B, which means there's not a seal at the proximal or distal landing zone of the graft so it's stuff leaking in either distally or proximally.
There's type two which is usually the result from back bleeding from one of your lumbars. There's type three which is a leak between the components of your grafts. And there's type four which is due to the porosity of the graft material. And then there's type five which is the endotension? Yeah. Which is defined as endotension. And it's still, I've read a lot about it and it's still confuses me how it's different than type four.
>> Don't lie. You have not read a lot about that. >> At one point in my life I read a lot about it. It's been a little while but I have read a lot about it. >> So you're performing your angio after your [inaudible] placement. What are the two types of endoleaks you have to fix right then and there? >> So type one, so if there's leakage either from either the proximal or distal landing zone, you have to repair that. And then type three, if there's leakage between the connection of the components, that needs repair.
>> Right. And what would be your indication for repairing the type two? >> So type two will generally stop on its own or generally remain stable. But however if the sac is enlarging, you do need to repair those as well. >> Great. Okay, John. We're going to dive into vascular surgery 101. How do calculate an ankle-brachial index? And I have seen this on tests before and you really actually need to know this. >> Yeah. The short answer is you take, you measure your pedal pressures and you take whichever is the highest, the DP or the PT, and you divide it by the highest brachial pressure and it can be either the right or the left arm.
>> Right. So if they give you the right arm of a pressure of systolic of 130 and they give you, but you're measuring the ABI in the left foot, you will still use the right arm as part of the denominator. So please don't forget that. Okay, John. Interpreting ABI's real briefly. We all know this but can you just tell us kind of your general rules for interpreting ABI's? >> Yeah. So I think of anything greater than .9 is normal up to 1.4, you can actually have higher than that if you have a patient with diabetes or whatnot.
Anything between .5 and .9, you may have a patient, they have some symptoms of claudication. Anything less than .5, you have typically a patient with rest pain. They may have rest pain, some people don't. And anything less than .3 will be a risk for tissue loss. >> Great. And one thing that we didn't spend any time on and we're not going to is the traumatic peripheral vascular disease. But generally you can really rely heavily on your ABI's, especially in the ABSITE, for traumatic vascular disease.
So you have some sort of distal extremity injury and you have a normal ABI, that will generally complete your workup. So if it's greater than .9, you're not going to need to do an angiogram. You can generally, so ABI's are very useful, especially in trauma, to reassure you about your patient. But, Jason, just as I said that, when are ABI's not reliable? >> So, I mean, so patients who are diabetic. And this is pretty typical. They'll give you a patient who has classic claudication or peripheral vascular disease symptoms and they'll say, well, their ABI is 1 and then they'll ask you what you want to do.
If that patient is diabetic, you can't rely on that ABI because their vessels are calcified. So you have to go a little more distal to their toe pressures. >> Great. Okay, John, I give you the patient that's out golfing and gets calf claudication. And they want to get a bypass surgery done. And it's the first time seeing you. What do you do for them? >> Yeah. This is [inaudible] for you. If you're like me, try to jump into operating on claudication right off the bat, but your first choice should be smoking cessation, exercise, and then [inaudible] and therapy.
>> And so what would your primary indications being for operating on claudication? >> So any patient coming in with critical ischemia. They'll usually present a patient with a severe looking right or left leg, or foot. And any patient who has a significant rest pain. >> Right. So you're going to have tissue loss is going to be the main indication for operating on peripheral [inaudible] and also rest pain are the two definite indications for operating.
So, Jason, how are you going to image vessels? You have a patient comes in. They have maybe have a little ulcer on their foot and you need to complete your workup here. >> Well, if you can, CTA. I mean, it's good, especially for proximal vessels, and specifically to the level of the knee. It's a little bit trickier distal to that. The problem is a lot of these patients have concomitant renal disease so they can't handle the contrast load.
So from there angiography can, if you can use less contrast to visualize the distal vessels, that's a good option. And if you really can't use any contrast at all, you have a CO2 angiography. >> Great. Yep. So, you know, generally you're not going to jump to angiography. CTA is quite good at analyzing inflow but distal to the leg the CTA becomes less helpful. Sometimes you need the angiography for that.
So, John, as far as planning vascular surgery goes, specifically bypass surgery, you've got a patient, they've got a long SFA occlusion, and not amenable to endovascular repair. What are the three basic principles of vascular surgery and repairing this? >> Yeah. So it's actually quite easy. You think of where are you going to get the blood flow from so that's your inflow, where it's going to leave, that's your outflow, and whether you have to bypass anything if you're using some times of vessel, or a vein, or another type of conduit.
>> Great. And so -- . >> Give me a minute. I thought inflow, outflow, and cash flow were the three principles of vascular surgery. >> That are people that are more naive. But the one thing I have seen is they'll give you a, you know, ask you about a pedal bypass in a patient that has very poor options for outflow, and they have great inflow and they have a great saphenous vein to use. But if it doesn't have a good outflow, or, you know, vice versa, it doesn't have a good inflow, these will not last.
Or if it doesn't have a good conduit and you're not going to want to do a distal extremity revascularization without a good conduit such as the saphenous vein. Okay. Briefly, Jason, can you just take us through patients that you would consider for endovascular versus open repair? >> So this can be a little complex. And I don't think we're going to get into the minutiae of the different task lesions and how to treat each one, but in general, and especially for the boards, you want to consider endovascular interventions for lesions that are short and not heavily calcified.
For longer lesion that are too long for a stent, or heavily calcified, you want to start leaning towards bypass. For things like the common femoral artery it's a little bit unusual to treat those endovascular just because they are so easily accessible and they're so mobile that they would be prone to kinking if you were to try endovascular approach. And again, just because they're so easily accessible operatively.
>> Yeah. It probably not terribly high yield but it might be worthwhile to take a look at the task criteria and that will help you determine which patients are best treated with endovascular versus open. But I really don't think that's terribly high yield so we'll keep driving on to some more high yield topics. So, John, a patient presents with buttock claudication, impotence, and absence of femoral pulses. What is the syndrome called and how will you treat it? >> So this is your Leriche's syndrome and you'd have aortic iliac disease.
>> Right. And so, Jason, I've heard of patients that also have aortic iliac bifurcation disease from an embolus. You know, they a-fib like we've talked about before, and they get a large embolus at the aortic iliac bifurcation. I would imagine Leriche and the embolus are treated the same. >> Not true. Leriche syndrome is a chronic, you know, atherosclerotic process so these patients would typically be treated with something like an aorta bi-fem.
Acute embolus of the aortic bifurcation is more obviously acute at onset and these patients need a bilateral transfemoral retrograde embolectomy with anticoagulation. So two different disease processes, two different approaches. >> Right. And kind of like our mesenteric ischemia embolus versus thrombosis, completely different treatments. Same at the aortic bifurcation and embolus. You can just do a embolectomy by just cutting down on the femoral vessels and doing retrograde embolectomies versus Leriche where they have a, you know, diseased aorta that needs a complete [inaudible] bifemoral bypass.
Okay. Just real quickly, I just want to make sure everyone takes a second and opens up Google when they get home or pull over to the side of the road, and look up an angiogram of the distal extremity. These are free points that are easy, but if you haven't looked at one in a while, you may not be able to identify the difference between the anterior tibial artery, the posterior tibial artery, and the perineal. The best way to think of this is the anterior tibial will be the first one that comes off, and then you'll branch off into your tibial perineal trunk.
The one that goes next to the fibula is going to be your perineal artery. The one that stays, believe it or not, behind the tibia is going to be your posterior tibial artery. Okay. So just take a second, open it up, look at it. It's going to get you a point on the ABSITE. So, Jason, I just want to cover one last thing. I, for whatever reason, can never remember the four compartments of lower leg. I know we've covered it already, but I just want to talk about what's actually in each compartment.
So starting with the lateral lower leg, what are those two compartments on the lateral side and what is in each of those compartments that's important? >> So on the lateral side you have your anterior and your lateral compartments. So in your anterior you're going to have your anterior tibial artery. In your lateral you're going to have your superficial perineal nerve. >> Great. And, John, for the medial part of your fasciotomies, what are those two compartments and what are in those compartments? >> So that's your superficial and deep posterior compartments.
And you superficial, the important ones are your gastroc is in there, and your sural nerve will be running in there as well. In your deep posterior compartment, it contains the tibial nerve, the posterior tibial artery, and the perineal artery. >> Right. So the deep posterior compartment, that is where most of the important things lie. You have your tibial nerve, your posterior tibial artery, and perineal artery. So the deep posterior compartment is right behind the tibia. And this is the access through your medial incision and this is what is so important about taking down that soleus so you can actually fully expose and access this compartment.
Okay. So anterior and lateral compartments are accessed from the lateral side. The medial side are the superficial and deep posterior compartments. Okay. Now I know you guys are really excited to talk about this topic. We're going to dive into diabetic foot infections. Okay. So, Jason, what vessels does diabetes affect? >> So diabetes affects your microvasculature so it's going to affect your small vessels, the feet, as well as classically it affects your tibial vessels.
>> Right. So smokers are generally going to get the aortoiliac disease, the more fun disease as far as surgeons are concerned, and diabetics get the tibial disease and the small vessel disease. Jason, you have a patient that comes in with a wound on their foot. They're diabetic. You know, maybe it looks a little funky. What is the first thing you want to rule out in this patient? >> Osteomyelitis. >> Okay. And so you rule out osteomyelitis but they have a little wound, a little cellulitis.
How long are you going to keep them on antibiotics for? >> Well, first, I think an important, well, let's return to that osteomyelitis thing. Because I know I've seen it a few times where they'll give you options of how you want to diagnose that. So they'll either give you imaging, and I think I would choose MRI as the best option. A lot of times they'll give you like bone biopsy or something like that. Don't choose that because what you'll end up doing is [inaudible] seeding where they didn't have osteomyelitis before, now they do. So MRI would be the diagnosis of choice for that.
>> Right. And so a lot of times the way they'll lead you away from MRI is that, you know, all these patients have multiple implants that aren't, you know, MRI compatible. And so then I believe the white [inaudible] white cell scan is the best. >> I agree. I think that's what I would go with. MRI first. If they can't for whatever reason, white blood cell scan, but steer clear of bone biopsy for diagnosis of osteomyelitis. >> And it is a little confusing because sometimes a wound biopsy is helpful but a bone biopsy will never be the answer.
Okay. So, John, say the osteo -- oh, sorry -- one thing we didn't finish covering was you want to continue the antibiotics until the ulcer base is clean and there's no evidence of cellulitis. So there's no definitive length on the antibiotics until the wound is healing appropriately and no evidence of cellulitis. So, John, say the MRI does show some increase uptake in the bone, and you're diagnosing osteomyelitis. Does the treatment differ? >> Yeah. It does. You want to proceed with debridement and you're going to do a debridement usually of these anyways but debridement to healthy bone and using a prolonged antibiotics for four to six weeks as well.
>> Great. And, Jason, so what if you have a non-healing ulcer and the angiogram identifies there is an inflow problem that can be corrected? >> Well, so this is a patient that you can consider a revascularization, however, you have to remember that this is a microvascular disease so in order, in addition to correcting the inflow, you need to have a good target vessel. >> Great. Okay. We're almost done with vascular. We have two last topics Venous disease is going to be the majority of our last topic.
Okay. For venous disease, we talked a little bit in the 2017 vascular update review about venous disease but one thing we didn't talk about was vascular venous trauma. So, John, what vessels in trauma, you've got an exsanguinating patient. This is not a minimally, you know, minimal trauma patient. This is a seriously ill trauma patient that has significant intra-abdominal bleeding. What vessels can you ligate in trauma as far as venous disease goes?
>> Yeah. So the easiest way to think about this for your test is that any vein distal to the renal veins. Obviously this comes with substantial morbidity but if the patient is dying, you have to consider it. >> Right. Okay. And then how about the renal veins themselves, Jason? Is there one that is able to be divided and one that's not? >> Yeah, but with some caveats. So you can divide the left renal vein if proximal to the gonadal vein and the gonadal vein is intact to allow retrograde drainage.
>> Right. And so if you cannot, so say it is your right renal vein is devastated in trauma in an ill patient, what is going to be your therapy? >> Well, if it's not amenable to repair and your patient's crashing, then you would need to do a nephrectomy. >> Great. Okay. So just key points to remember is that any vein distal to the renal veins can be divided, ligated in trauma. You will suffer significant morbidity and problems but if it is to save their life, that is an option.
John, one last thing about venous disease that we see frequently. You have a patient comes in with a swollen, blue leg. What are you worried about and what is the treatment? >> Yeah. This is classic for phlegmasia cerulea dolens and it's an iliofemoral DVT and they will need a catherter-directed thrombolysis. >> Right. So these patients have what is an iliofemoral DVT, very large DVT, and these patients need a urgent thrombolysis.
So, Jason, which, on venous disease we're going to dive a little bit into DVT's, deep venous thrombosis. What is the most common location of the DVT and which leg has a higher rate of DVT? >> So your iliofemoral location is the highest location for a deep venous thrombosis and the left leg is more prone to forming these. >> Why is the left leg more prone? >> So it has to do with your anatomy. So your right iliac artery crosses over and can compress your left iliac vein ever so slightly.
>> And what is that syndrome called? >> May-Thurner syndrome. >> Yes. It's a very important thing to know. And I don't think this would come up on the test, but stenting the iliac vein is the treatment for that. John, you have a trauma patient. They have a head bleed. And you note bilateral PE's in this patient. What is this an indication for and where are you going to, how are you going to do this?
>> So these patients would warrant and IVC filter among a bunch of other reasons why you'd place IVC filter. But the ones you'd see in a test on the outside of patient who'd had a recent bleeding, recent head injury with bleeding as well. But you want to place the IVC filter distal to the renal veins. >> Right. And so for the test you generally use the right IJ because it's the most direct access to the vena cava. You go through the superior vena cava, inferior vena cava distal to the renal veins and place your IVC filter.
Important to know that, maybe look at a little video of that. Some seems to be a common question. Okay, Jason, to close out vascular surgery, our favorite topic is DVT's, some more DVT's. Provoked DVT, how long are you going to treat these patients? >> Provoked DVT, the treatment is three months. >> What does a provoked DVT mean? >> So that's somebody who's had either like a surgery, trauma, any reason to have a DVT.
>> Right. So a patient has a DVT and PE from trauma or you did bariatric surgery on them, something. Three months of therapy and then kind of reevaluate. John, how about a patient that has metastatic colorectal cancer and they got a DVT and PE in their hospital stay, how long do you leave them on therapy? >> Yeah, so you want to continue therapy until you no longer have that cancer or they've been cured. >> Great. And then how about a patient that has a hypercoagulable disorder?
>> Those patients get lifelong therapy. >> What is the most common hypercoagulable disorder? >> Factor V Leiden. >> Great. And we have a great hematology episode in 2017 that you can learn about that. >> I guess we should preface that with the most common inherited or genetic hypercoagulable disorder. Most common hypercoagulable disorder, I think, is probably smoking, would you say? >> Yes. You just saved me about five emails. Thank you for clarifying that.
And that was probably at least a couple of four-star reviews if I had missed that. >> I would have given that a three. >> Okay. So to close out vascular for good, let's go through our quick hits. Jason, how do you access the SMA in trauma? >> So you lift the transverse colon and mobilize the ligament of Treitz. >> John, how do you expose the superceliac aorta in trauma? >> So you want to enter the lesser sac through the gastrosplenic ligament and divide down to the posterior cruciate so you can compress the aorta from there.
>> Jason, what is the biggest risk factor for ischemic colitis in a patient that had a triple A repaired? >> Pre-op hypotension. >> Okay. And a few of our favorite vasculitises. John, you have an old lady with headaches, has temporal blindness, quote unquote, and fatigue. What is this and how do you treat it? >> Yeah. This is classic for temporal arteritis. You can diagnose it with the temporal artery biopsy. And the treatment is with corticosteroids.
>> Jason, Buerger's disease. This is the guy that's smoking and has digital ischemia. What vessels are affected in Buerger's disease? >> So that's a small and medium vessel disease. >> All right. And even though mycotic refers to fungi in vascular, that is not the case. So, Jason, what is the most common organism in a mycotic aneurysm? >> Staphylococcus. >> I hope you guys learned something from our ABSITE Vascular Review 2018.
And join us back for some breast cancer review.