Download Manual of Vascular Surgery by Edwin J. Wylie M.D., Ronald J. Stoney M.D., William K. PDF

By Edwin J. Wylie M.D., Ronald J. Stoney M.D., William K. Ehrenfeld M.D. (auth.)

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53 Carotid Atherosclerosis Fig. 10. Endarterectomy specimen showing an early stage of atherosclerosis in which an ulcer has already developed. The normal-appearing intima at the left end of the specimen is at the end point of disease in the distal internal carotid artery. Fig. 11. Endarterectomy specimen showing mural degeneration in the bulb of the internal carotid and a long tongue of distal atheroma. Except for one other patient with unoperable disease extending to the bony foramen this is the longest distal extension of atherosclerosis we have encountered in over 2000 carotid endarterectomies.

Less so is the internal carotid artery distal to the carotid bulb, but one should suspect the presence of a clamp defect ifless than the anticipated backftow occurs after release of the distal clamp. The defect is overcome by passage of an arterial dilator of appropriate size (2 mm in profunda branches, 4 mm in the carotid artery). It is important to avoid reapplication of clamps; Fig. 35a and b illustrates a hypothetical situation in which a dilator is being passed before the application of the final sutures in a venous patch graft.

Because of numerous previous abdominal operations, a crossover graft was used to revascularize the left profunda femoris artery. One year later the patient returned with acute ischemia of the left leg secondary to thrombosis of the crossover graft. At operation, fresh thrombus was found in a graft that had become narrowed by a chronic circumferential thrombus reducing the lumen diameter to 5 mm, the size of the profunda femoris to which it had been attached. c End-on view of a cut section of the crossover graft.

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