Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_857_Библиотеки_им_академика_М_И_Перельмана

veins. Compression with sponge sticks or use of an intravascular balloon for control of the vessel may be easiest. Approach to repair of the posterior wall is easiest through the anterior laceration if rotating by ligating the lumbar veins is difcult. Inferior vena cava may be ligated while the vena cava superior to the renal vein on the right needs to be repaired to preserve the right kidney. Portal vein may be ligated if the hepatic artery is pre­served but will also require vigorous uid resusci­tation because of sudden intestinal edema.

Vessels smaller than 3 mm can be ligated, while those greater then 3mm should be suture­ligated or if larger than 5mm closed with a run­ning suture for low-pressure vessels and two layers for high-pressure arteries. During repairs, it is important to touch the intima only very deli­cately, or not at all, and use stay sutures instead. Sizing of the patch is important to avoid oversize and aneurysmal dilatation and thrombus forma­tion. With small vessels, both ends should be spatulated, and the use of a sterile angiocath or sterile feeding tube in both ends of the anastomo­ses will facilitate avoidance of suturing two walls together.

intense uid resuscitation, while some may have to return to the OR for a second look at bowel viability. Ligation of IVC or iliac veins requires leg elevation and elastic stockings or Ace bandage wrapping to avoid leg edema. Possible thromboses of small vessels, pseudoan­eurysm formation, embolism, and vascular breakdown of the anastomoses with infection or without are problems that may be encountered and require patient proximity to hospital staff for about 3–4weeks.

on essential equipment, supplies, and personnel for provision of vascular care.

In 2016, multinational consensus recommenda­tions were published in an effort to better charac­terize the services and resources needed to provide essential vascular care [26]. This assessment was designed to outline the resources and services needed to assess and triage common vascular con­ditions at various levels of a national healthcare system, regardless of national income. As the bur­den of vascular disease continues to increase, it is essential for providers to understand the assess­ment and treatment options available in LMICs in order to provide high-quality patient care in any environment. Existing data suggest that outside of tertiary centers, perioperative equipment and sup­plies were not reliably available, even such as basic airway equipment and electronic cardiac monitoring. At some tertiary hospitals, there was lack of mechanical ventilation support, electronic cardiac monitoring, or arterial blood gas and blood chemistry analysis [25].

importantly, (3) transfer to an adequately equipped tertiary center with well-trained staff. Classically, chronic limb ischemia was dened using the Fontaine or Rutherford classications; however, in 2014, the Society for Vascular Surgery proposed a new classication for strati­fying chronically threatened limbs based on three clinical parameters: wound, infection, and isch­emia (WIfI) classication [31]. This new grading system offered several advantages but speci­cally accounted for the presence or absence of infection, which dramatically impacts the suc­cess of limb salvage. Although revascularization is the mainstay treatment of CLTI, patients should continue to receive appropriate medical therapy to minimize the damage from vascular disease including cardiac optimization, glycemic and lipid control, daily exercise, and, most impor­tantly, insistence on tobacco cessation. Discussion of CLTI must include a wide variety of vascular insufciencies with a variety of pathologies that are beyond the purpose of this chapter since the major chronic vascular problems, as compared to the acute events, need to be addressed in LMICs in tertiary (usually university) centers, which are adequately staffed by trained personnel and have adequate diagnostic and therapeutic equipment, as well as vascular instruments, sutures, and prosthetic grafts. These are usually lacking in pri­mary local and even in many regional hospitals [25]. Aortoiliac atherosclerotic disease, often described as inow disease, should be suspected in vasculopaths with nonpalpable femoral pulses. These patients should be promptly transferred to tertiary centers whenever possible, once stabi­lized. The approach to ruptured aortic aneurysm is similar to that described briey to management of the traumatic injury of the aorta. Elective treat­ment of infrainguinal disease and tibioperoneal disease should also be promptly transferred to the care of specialists unless gangrene with sepsis has intervened, in which case an amputation may be required to save the patient’s life. Even the presence of early gangrene should prompt trans­fer to a tertiary center for revascularization and to save as much of the leg as possible with adequate blood supply to the skin ap to allow good heal­ing of the stump and tting of a prosthesis.