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Protocol algorithm for codes
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J. K. Ballast et al.
approaches that targeted infrastructure, clinical care, systems, education, and electronic tools did improve patient
care by decreasing time to diagnosis and surgical repair and
increasing the use of beta blockers and intraoperative TEEE
imaging [50]. Multidisciplinary centers should thus develop
protocols to standardize and streamline pathways of care.
Protocols may address elective and emergent cases,
along with functional aspects of care. An aortic center
should develop elective and functional protocols to structure and organize diagnostic processes, basic procedural
techniques, OR and ICU care, and postoperative management. Protocols for initial treatment should address radiologic evaluation, initial stabilization, and management.
Functional protocols may address ventilation weaning and
extubation, along with pain and blood pressure control.
Emergent protocols such as “code aorta” or “code rupture”
streamline patient transport, imaging, and team mobilization, creating a life-saving reduction in time from presentation to intervention. Emergent protocols should address
what tests should be done and what criteria a patient should
fulll in order for a code to be called, along with outlining
Fig. 40.4 Protocol design.
Any protocol or code should
standardize and streamline
care for patients. In a
multidisciplinary center, the
importance of effective
protocols is increased, as the
wider range of specialists
involved in patient care
necessitates planning for
pathways of collaboration
Critical
patient transport and team activation (Fig. 40.4). Once
implemented and proven efcient in the setting of the aortic
center, emergent protocols should be offered and implemented in surrounding institutions and the community in
order to provide rapid diagnosis, transport, and treatment to
a wider radius of patients.
Aortic Clinics andElectronic Health Records
Developing an aortic clinic may be benecial to the center
and institution at many levels. An outpatient clinic provides
opportunities for outreach and screening initiatives, as well
as clinical education programs. A clinic can provide a simple point of contact for referring physicians, emergency
departments, and patients while also standardizing pre- and
postoperative testing and surveillance. Creation of a clinic
within the multidisciplinary aortic center provides an information link with surrounding facilities and within the center itself, allowing the integration of information from
referring physicians and multidisciplinary experts. The
ED or referral physician
initiates code
Assessment of urgency:
• Hemodynamic Stability
• Neurological Status
• Ischemic Changes
• Risk Factors
Non-critical
Operating room
Assessment of
pathology, prep for
procedure
As indicated by surgeon
Open repair
Endovascular
repair
Review imaging
and labs
Multidisciplinary
care planning
40 Multidisciplinary Aortic Centers
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481
adoption of electronic health records (EHR) may be key in
improving communication and collaboration in a multidisciplinary center and its contributing network. In a clinical
care setting, EHR allow everyone involved in a patient’s
care to easily access relevant information, streamlining
care by preventing redundancy and ensuring timely and
accurate documentation. In 2012, less than half of US hospitals had successfully implemented EHR, suggesting that
this may be an area to target in small and rural hospitals, to
provide external as well as internal continuity [51].
However, the use of EHR is increasing due to nancial
incentives for EHR who fulll “meaningful use” criteria
[52]. The creation of a clinic, along with the use of EHR,
contributes not only to quality and coordination of care but
also to the quality of information provided for research
using an aortic database.
Benets ofaGrowing Program
There are many benets in developing a multidisciplinary
aortic center. The increase in volume as reputation increases
improves patient outcomes and provides research opportunities. Multidisciplinary centers also have the capacity to
improve patient satisfaction, an increasingly important
consideration in the shift to value-based reimbursement.
Despite the high initial capital investment, multidisciplinary centers have the potential to produce returns on
investment, providing system-wide benets for the institution and its contributors.
Volume andOutcomes
Increased physician and hospital volume has been associated with improved patient outcomes, possibly due to the
expertise generated by repetition of highly specialized procedures [53–55]. There has been a trend in recent years
toward the regionalization of AAA repair, with the percentage of AAA repairs performed at high-volume centers
increasing from 12.9% to 30.9% between 1998 and 2004
[56]. In a 2009 study utilizing the Healthcare Cost and
Utilization Project’s Nationwide Inpatient Sample, McPhee
and colleagues found that high-volume centers and teaching institutions were associated with lower mortality rates
in patients undergoing endovascular repair for abdominal
aortic aneurysms [57]. In 2002, a study using information
from the national Medicare claims database and Nationwide
Inpatient Sample examined the mortality rates associated
with six types of cardiovascular procedures as they related
to hospital volume. Although the percentage of mortality
rate decrease associated with high-volume hospitals was
less than 2% in some procedures, the consistent decrease in
hospital mortality rates further supports the trend toward
performing complex cardiovascular procedures in highvolume centers to improve outcomes [
analysis of Medicare claims mortality data [59] and an
analysis conducted by the nonprot Leapfrog Group [60]
both found an inverse relationship between institutional
volume and mortality in a range of surgical procedures.
Although there is some controversy surrounding this issue
[61–63], increased procedural volume does appear to
reduce complications and improve patient outcomes [64].
58]. In fact, a 2014
Research, Registries, andClinical Trials
A center’s increased volume and recognition will provide
opportunities to participate in and conduct research regarding aortic pathology and treatment. One such opportunity
may involve collaborating with industry partners to conduct
clinical trials evaluating treatments and technology. Because
of the specic requirements establishing criteria for patients
to be involved in clinical trials, having a higher surgical volume will increase the likelihood of treating qualifying
patients. Participation in trials for stent grafts, medications,
and other treatment techniques and technologies can provide
valuable information about effectiveness and outcomes, contributing to the eld and promoting innovation.
With the increase in volume that is likely to result from
the creation of a center, multidisciplinary aortic centers also
have the opportunity and responsibility to expand registries
and research efforts to improve clinical quality tracking and
benchmarking. Creation of registries to drive performance
improvement are one of the most challenging areas related to
vascular services, and outcomes-based registries for vascular
services are under-represented [65]. Barriers to creation of
effective registries include the wide range of vascular interventions and unclear quality endpoints. The research potential provided by expanded vascular registries will improve
identication and early diagnosis of potential patients, along
with informing best practice protocols for technology, procedure, and care strategies. The development of such registries
will facilitate performance monitoring and allow data-driven
performance improvement, along with providing data to
improve outcomes-based research identifying genetic, social,
behavioral, and other factors contributing to vascular disease
and sources of poor patient outcomes.
Planning how data will be collected and how outcomes
will be tracked is important in the development of a
multidisciplinary center [66]. Research collected should
allow the center to monitor and improve morbidity and
mortality rates, present cumulative history and experience,
track referral patterns, and provide the ability to present
outcomes. Registry design should be undertaken by planning committees involving all stakeholders and should
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incorporate comprehensive longitudinal data on disease
management, risk modication, and medical treatment as
well as procedural interventions. Vascular benchmarks
should be established, such as in- hospital mortality rate,
length of stay, readmission rate, and nancial aspects of
care [67]. The use of protocols to standardize pathways of
care can facilitate improved collection and monitoring of
outcomes data. Patient-tracking capabilities are essential,
as providing standardized outcomes data builds institutional knowledge and outcomes and can also contribute to
collaborative research initiatives. EHR may thus play a
novel role beyond clinical care, providing information for
research purposes [68]. The regular generation of patientspecic information results in vast amounts of data with the
potential to signicantly contribute to research. However, it
is important to employ mechanisms to ensure quality of
data provided by EHR, as there is potential for incomplete
and inaccurate data capture [69]. Ensuring adequate
resource support for the creation and management of registries is essential to the collection of quality data, as is the
establishment of standardized protocols, staff accountability, and regular committee review.
Patient Satisfaction andQuality ofCare
A multidisciplinary center has the capacity to improve quality of care and patient satisfaction. Patient satisfaction is
becoming an important consideration in healthcare since pay
for performance and value-based reimbursement programs
depend partially on patient satisfaction and experiences to
determine nancial bonuses. It has been shown that patient
satisfaction may be a multidimensional concept that may not
serve as a valid quality indicator and that the relationship
between patient satisfaction and outcomes and cost is not
well-dened [70, 71]. However, having patient satisfaction
may improve patient outcomes because satised patients are
more likely to comply with treatment plans, seek advice,
maintain a relationship with their physician, and come in for
follow-up, all key elements to successful long-term management of disease [72–74]. The use of electronic health records,
when there is emphasis on physician dialogue and communication, has been shown to engage patients and allow them to
feel more involved and in control of their care, increasing
satisfaction [75]. Other factors associated with patient satisfaction include hospital size, surgical volume, low mortality,
and hospital stay experience [76]. However, nursing may be
the key area to highlight in increasing patient satisfaction, as
patient satisfaction has been associated with a variety of
nursing factors [77, 78]. In particular, interpersonal care
experiences have been shown to inuence patient satisfac-
tion and may independently impact outcomes secondary to
the therapeutic relationship combining emotional and cognitive care [
undeniably linked to quality of care, it may be associated and
is worth examining, especially as healthcare shifts from a
focus on the physician and volume toward patient and value
focus.
79]. Overall, while patient satisfaction cannot be
Return onInvestment
Development costs and capital investment are notable in the
creation of an aortic center. Depending on the initial capacities and capabilities of the institution, operational costs may
increase as 24-hour teams are implemented. However, the
most costly investments are likely to be equipment required
to provide for a range of treatments and care. Hybrid suites
and support equipment, along with stocking of stent, wire,
and catheter inventory, are necessary for the treatment of
various aortic pathologies but represent signicant costs
which should be addressed in creating a business plan. It is
difcult to generalize about institutional gains provided by
the development of a multidisciplinary aortic center since
models vary signicantly between various existing centers.
However, initial capital investments are likely to be offset by
increased volume as reputation improves. While the initial
nancial and resource requirements to create a multidisciplinary aortic center involve a signicant capital investment,
a center can expect to benet in the long term from quality
improvement and associated cost savings. Many hospital
systems receive much of their reimbursement from Medicare
and Medicaid. With the shifting state of insurance designs
and coverage, the health care system must adapt and adjust
to transitions to stay solvent [80]. The Affordable Care Act is
currently driving the transformation to a value-based insurance design [81–83]. This model emphasizes individual
patient care and offers incentives for systems who adopt the
guidelines for “Accountable Care Organizations” set forth by
Centers for Medicare and Medicaid Services (CMS) [84].
These guidelines also reward the reduction in readmissions
secondary to infection, the use of electronic health records,
and preventative services, basing incentives on relative
improvement as well as reaching CMS-established benchmarks. As health care plans continue to shift with new political leadership, all health care systems, including aortic
centers, must be prepared to adapt their strategies to uncertain developments and policies [85]. However, it seems
likely that the emphasis on payments tied to quality or value
is a trend that will continue, with Health and Human Services
having set a goal of tying 90% of all Medicare payments to
value or quality by 2018 [86]. Therefore, the development of
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multidisciplinary care, which offers a high quality of care
and increased value due to its ability to provide a crosscontinuum of care, is likely to result in returns on investment, as reimbursement becomes tied to longitudinal
efciency and outcomes.
Conclusions
A multidisciplinary aortic center has the capacity to improve
patient outcomes by coordinating a multidisciplinary team of
experts and specialists who collaborate to improve diagnosis, treatment, and longitudinal surveillance of aortic pathology, providing a cross-continuum of care. Creation of such a
center involves planning to determine organization and
structure, the development of vascular and multidisciplinary
teams, and the mechanisms for their collaboration, as well as
targeted marketing and networking to identify patients and
create a strong referral base. Contributions to the eld
through research and innovation and the ability to offer highquality care support the move toward a multidisciplinary
approach to aortic care. The development of a multidisciplinary aortic center has been shown to have many benets,
and further research will identify even more common features of successful centers in order to inform future models
for multidisciplinary aortic centers.
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Index
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A
Abdominal aortic aneurysm (AAA)
anti AAA drugs, 78
classication, 200–202
crescent sign and drape sign, 205
CT angiography, 211
denition, 47, 293
familial, 58
genetics
animal models, 76
cellular pathology, 76–77
characteristics, 69–79
expansion, 70
gene and cell therapy of, 79
genetic subtypes, 70
loci affecting cell proliferation, 73–75
loci affecting lipid metabolism, 71–73
origin with genetic mutations, 70
pharmacological treatment, 77–79
functional imaging, 207
magnetic resonance imaging, 207
molecular imaging, 207
spiral computed tomographic and computed tomographic
angiography, 205
ultrasound, 204
infrarenal, 293
9 loci of, 70
mouse models, 71
natural history, 293
pathophysiology, 202
risk factors
age, 202
alcohol intake, 203
atherosclerosis, 202
family history /genetic factors, 203
gender, 203
hyperlipidemia, 203
hypertension, 203
non-ruptured, 204
primary disorders of aorta, 203–204
ruptured, 204
smoking, 203
screening recommendations, 205
signs of impending, 206
size and risk of rupture, 208
surveillance, 207–209
surveillance interval recommendations, 208
treatment options
behavioral modications, 209
current guidelines, 212
juxtarenal/suprarenal, 212
pharmacologic interventions, 209–210
surgical and endovascular aneurysm repair, 210
timing of intervention, 210–212
type II endoleak, 208
Abdominal aortic aneurysm (AAA) repair
acute postoperative renal insufciency, 299
aortobiiliac/aortobifemoral repair, 295
elective open surgical treatment
cause of death, 294
considerations, 294
patient evaluation, 294
preoperative assessment, 294
expanded polytetrauoroethylene, 295, 296
hybrid (combined surgical and endovascular) repair, 299–300
indications, 294
knitted and woven polyester grafts, 295
long-term survival, 299
midline incision, 296
operative technique, 296–298
outcomes, 299
retroperitoneal approach, 298
tube graft repair, 295
Abdominal aortic injury, see Blunt abdominal aortic injury (BAAI)
Abdominal coarctation, 120–121
Abdominal dissection, 224–225
Aberrant right subclavian artery, 108
ACTA2, 32, 63, 64
Activated clotting time (ACT), 182, 278
Acute aortic occlusion
diagnostic tests, 423
etiology, 421
Acute aortic syndromes
chronicity, 150
classication of, 130, 151
clinical presentation, 151
denition, 149
diagnosis, 152–153
epidemiology and risk factors, 150–151
natural history, 151
pathogenesis, 150
and pregnancy, 150
treatment
clinical stability, 153
fenestration, 154
indications for surgery, 153
initial medical management, 153
interventional options, 153–154
longitudinal follow up, 155
prognosis, 155–156
thoracic endovascular aortic repair (TEVAR), 154–155
uncomplicated type B dissection, 155
© Springer Nature Switzerland AG 2019
R. S. Dieter et al. (eds.), Diseases of the Aorta, https://doi.org/10.1007/978-3-030-11322-3
487
488
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Index
Acute aortic thrombosis
case study, 422
causes, 422
etiology, 421–422
oating aortic thrombus, 424
free oating, 422
positional considerations, for surgical therapy, 422
therapeutic approach, 423–424
thrombotic thrombocytopenia, 422
Acute aortoinfrarenal duodenal/enteric stula, 376
Acute type A aortic dissection (ATAAD)
biomarkers, 128
cannulation strategy, 136–137
classication, 128
clinical presentation, 128
comorbidities, 128
diagnostic error, 133
EKG ndings, 128
epidemiology, 127
extent of repair and risk of reoperation, 134
frozen elephant trunk technique, 134–136
imaging, 130, 132
incidence, 127
management, 133–137
Marfan syndrome, 136
medical-only approach, 133–134
outcomes
age, 138
follow-up, 139
iatrogenic aortic dissection, 139
LV function, 139
malperfusion, 137
mortality, 137–139
pregnancy, 139
race, 138
sex, 138
presentation, 130
root repair, 136
surgical approach, 134–137
total arch replacement, 134
American Association for the Surgery of Trauma (AAST), 401
American Society of Echocardiography, 88
Amplatzer Septal Occluder devices, 461
Aneurysm
geometry, 35
morphologies, 201
Angiotensin-converting enzyme (ACEi) inhibitors, 431
Ankylosing spondylitis, 464
aortitis, 244
characteristics, 243
clinical presentation and diagnosis, 244
management, 244–245
Anomalous right subclavian artery, 13–15
Antegrade cerebral perfusion, 279
Aorta
abdominal, 17–18
anatomy, 199, 200
aortic arch anomalies, 11
embrological development, 9
pseudoaneurysm, location, 458
Aortic airway lesions, treatment of, 366
Aortic aneurysm, 323
ascending, 171
bicuspid aortic valve, 166
clinical presentation, 167–168
congenital, 164–166
denition, 45, 161
degeneration, 163
during 1800s, 2
during 1940s to date, 3–4
during 20th and 21st century, 4–6
early 1900s of the 20th Century, 3
early history, 1–2
Ehlers-Danlos syndrome, 165–166
epidemiology, 162
historical perspective, 161
imaging modalities
computed tomography, 169
imaging modality, 169
leading edge measurements, 168
magnetic resonance imaging, 169
transesophageal echocardiography, 169
transthoracic echocardiography, 168
infections, 166
Loeys-Dietz syndrome (LDS), 166
Marfan syndrome, 164
noninfectious inammatory syndromes, 166–167
operative technique, 170–171
outcomes, 171–172
pathology, 163
repair, 171
surgical anatomy, 161–162
surgical indications, 170
surgical repair on, 170
Aortic arch
anatomy, 175
aneurysm repair
endovascular and hybrid, 183
hybrid procedures, 183–185
anterior view, 176
branch vessel anomalies, 175
development, 10
disease, surgical treatment, 279–280
stulas, 358
imaging, 177–178
indications
acute, 178
chronic, 178
pathophysiology
aneurysms, 175–176
dissections, 176–177
trauma, 177
plaques, 427
presentation, 177
repair, 281
Aortic arch TEVAR
branched stent grafts, 313
chimney stent grafting, 314
chimney stent grating, 313
double branched endografts, 317–318
fenestrated stent grafts, 313
fusion imaging, 307
hybrid repair, 310–313
intravascular ultrasound, 307
preoperative diagnostic imaging, 307
single branched endografts, 316–317
surveillance imaging, 319
transcranial Doppler, 308
triple branched endograft, 318
Aortic atheroma, transesophageal echocardiography grading, 428
Aortic bifurcation disease, 222
Aortic cannulation, 277
Aortic disease
cocaine abuse, 50
congenital, 49–50
in elderly, 49
Index
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489
in pregnancy
antihypertensive uses, 436
coarctation of aorta, 438
Ehlers-Danlos syndrome, 437
epidemiology, 435–436
Loeys-Dietz syndrome, 437
management, 436
Marfan syndrome, 437
physiologic changes, 435
Turner syndrome, 437–438
systemic hypertension, 50
in young, 49
Aortic dissection (AoD), 416
characteristics, 149
classication of, 47, 177
denition, 47
Aortic stulas, 358, 363
locations in enteral system, 375
prosthetic aortic graft intervention, 382
thoracic, 355
treatment, 360–361, 363
Aortic isthmus, 399
Aortic left ventricular defect, 358
Aortic occlusion, 218
Aortic pseudoaneurysm
Amplatzer Septal Occluder devices, 460, 461
classication, 458
coil embolization, 460
complications, 457
description, 457
endovascular repair methods, 458
epidemiology, 457
imaging technique, 458, 459
life-threatening conditions, 458
open surgery, 459, 460
outcomes, 461
pathophysiology, 457
stent craft, 460
stent graft, 460
ultrasound-guided thrombin injection, 460
Aortic reconstruction, 264, 269
Aortic root
anastomosis, 278
anatomy, 162
repair, 277
Aortic sinuses, 452
Aortic thrombosis, see Acute aortic thrombosis
Aortic thrombus, 428–429
Aortic trauma, see Traumatic aortic injury
Aortic tumors
aortic wall location, 391
classication, 386
description, 385
diagnosis, 388, 389
differential diagnosis, 389–390
echocardiography, 390
endovascular techniques, 392
laboratory testing, 388
location, 390
metastatic, 386
non-aortic primary tumors, 391
physical exam, 388
preoperative biopsy, 389
primary, 385, 386
risks, 388
symptoms, 387
treatment, 391–393
Aortic urinary bladder stula, 353
Aortic valve
annuloplasty techniques, 452
annulus brosis, 449
aortic root, 449
aorto-ventricular junction, 451, 452
bicuspid, 450
commissures, 449
leaet, 454
leaet augmentation, 452, 454
Ozaki technique, 455
regurgitation, 450
congenital valvar stenosis, 450
Marfan syndrome, 450
post-balloon regurgitation, 450
rheumatic disease, 450
subaortic stenosis, 450
rheumatic, 450
sino tubular junction, 455
stenosis, 450
surgical intervention, 450–451
tricuspidization technique, 455
valvuloplasty, 451, 455, 456
Aortic valvuloplasty, 451, 455, 456
Aortitis, 51, 259
with ankylosing spondylitis, 244
Aortoappendiceal stula formation, 382
Aorto-bifemoral bypass, 223–225, 227, 228
Aortobifemoral bypass reconstruction
AIOD, 302–304
Aortobiliary stula, 375
Aortobronchial stula, 364, 366, 367
Aortocaval stula, 341
anatomy, 341
endovascular repair, 345–346
epidemiology, 341
hybrid approach, 346
incidence, 341
mortality, 341
open repairs, 344–345
pathophysiology, 341, 343
patient presentation, 343
physiology, 341
preoperative care, 343
Aortocolonic stula, 375
Aortocutaneous stulas, 367–368
Aortoduodenal stula, 375, 379
repair, 380
Aortoenteric stula
associated causes/risk, 376–377
case study, 379–382
classication, 375
denition, 375
diagnosis
computerized tomographic
angiography, 378
gastrointestinal bleeding, 377, 378
nuclear medicine studies, 378
patient history and physical
examination, 377
positron emission tomography, 378
etiology, 375–377
infectious organisms associated with, 377
physical ndings, 376
prognosis, 382–383
symptomatology, 376
treatment, 378–380
490
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Index
Aortoesophageal stula, 369
causes, 371
diagnostic evaluation, 370–371
etiology, 371–372
Kommerell Diverticulum pressure effect, 371
massive esophageal bleeding, 373
postoperative concerns, 373
prognosis, 373
signs and symptoms, 369
symptomatology, 369–370
treatment options, 372–373
Aortofemoral graft proximal anastomosis, 226
Aortogastric stula, 375
Aortography, 212
blunt thoracic aortic injury, 404
Aortoiliac disease, 217–219
Aortoiliac endarterectomy, 225–227
AIOD, 304–305
Aortoiliac lesions
reentry catheters, 222
Trans Atlantic Inter-Societal Classication, 221
Aortoiliac occlusive disease (AIOD)
aortobifemoral bypass grafting, 302
aortoiliac endarterectomy, 304
axillofemoral reconstruction, 305
clinical manifestation, 301
clinical presentation, 218
diagnosis
arteriography, 219
axial imaging, 219
patient history, 218–219
physical examination, 218
vascular laboratory, 219
epidemiology, 217
location for, 302
patient factors, 301
pathophysiology, 217
risk factors, 301
treatment modalities
antiplatelet therapy, 220
decision making to intervention, 220
diabetic control, 219
dyslipidemia, 219
endovascular intervention, 220–223
hypertension, 220
lesion crossing, 222
medical therapy, 220
smoking cessation, 219
supervised exercise therapy, 220
Aortojejunal stula, 376, 379
Aortopulmonary artery stula, 360
Aortopulmonary septal defect, 357
Aortorenal stula, 349
Aortorenal vein stula, 352, 353
Aorto-small bowel stula, 375
Aortotracheobronchial stula, 364
causes of, 364, 365
diagnosis, 366
catheter angiography, 366
endoscopy, 366
intravenous contrast CT, 366
non-interventional laboratory tests, 366
patient history, 365
symptoms, 365
treatment, 366–367
Aortoureteral stula, 350, 352
Aortourinary (AU) stula
diagnostic studies, 350–351
etiology, 349–350
prevention, 352
secondary causes of, 350
signs and symptoms, 349
treatment, 351
anatomic bypass procedures, 351
endovascular stent graft technique, 351, 352
interventional therapy, 351
ligation/patch grafting procedures, 351
therapeutic goals, 351
Aortouterine stula, 353, 356, 357
Arterial thrombosis, 421
Arterial tortuosity syndrome (ATS), 63
Arteriovenous stula, 359
Ascending aneurysm
and dissection, mechanics of, 34–36
formation, 37
Ascending aorta
developmental biology of
adventitial origins, 29
endothelial origins, 24–25
media origins, 24–27
micromechanics and structure, 29
patterns of, 24–29
genetic syndromes, 38
mechanics, 21
Ascending aorta TEVAR
anatomical considerations, 308
anatomical requirements, 308
branched stent graft, 308
FreeFlo stent, 310
fusion imaging, 307
indications and contraindications, 308
intravascular ultrasound, 307
preoperative diagnostic imaging, 307
surveillance imaging, 318–319
thoracic stent grafts, 308
transcranial Doppler, 308
Valiant PS-IDE, 310
Zenith Ascend TAA endovascular graft, 309
Ascending aortic aneurysm repair, 281
Aspirin, 223, 430
Astigmatism, 463
Atheroma, 51
Atherosclerosis, 50–51
of abdominal aorta, 217
histological classication, 427
mild, 51
risk of embolism, 429
severe, 51
surgical interventions, 432
Atherosclerotic lesions, 427–428
Atherothrombosis, 429, 430
angiotensin-converting enzyme inhibitors, 431
atherosclerotic plaque stabilization, 432
dual antiplatelet therapy, 430, 431
lipid lowering therapy, 431
renin-angiotensin system, 431
statin induced plaque stabilization, 431
statin therapy, 431
surgical interventions, 432
Axillary artery dissection and cannulation, 181
Axillo-femoral bypass, 227, 228
Axillofemoral reconstruction, AIOD, 305
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