Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3736_Библиотеки_им_академика_М_И_Перельмана

recommend if thrombus has propagated (even if remaining in the distal veins).

The CHEST Guidelines can help aid clinician decision-making based on DVT classication. CHEST recommends serial imaging (weekly venous ultrasound) for 2 weeks instead of anticoagulation in patients with isolated distal DVT of the leg without severe symptoms or risk factors for extension. Upon repeat imaging, AC is not recommended if no extension is seen and is

The CHEST guidelines also provide recom-

Patients should undergo repeat venous ultra-

should be treated for a minimum of 3–6months

with the option of extending duration of

therapy.

• When selecting AC, DOACs are preferred

Aortic aneurysms often occur in the setting of other concomitant diseases. Most AAAs are related to atherosclerotic disease (Table28.2).

Incidence of AAA increases in males age

greater than 60 years and females greater than 70years of age. Males are more likely to develop AAA than females. However, females are more likely to rupture at a smaller size than males [5]. Genetic conditions that are known to be associ­ated with developing aortic aneurysms include Ehlers-Danlos syndrome (EDS) and Marfan’s syndrome. These conditions are more concerning in patients who present with aneurysms at a younger age. There is high association between smoking and development of aneurysm.

Aortic aneurysms are managed medically with regular imaging surveillance until they reach size criteria for surgical intervention. A goal of aneu-

rysmal disease is early detection, surveillance, and elective repair to prevent complications of rupture, thrombosis, or embolism. The diagnosis and treatment will depend on stability of the aneurysm [5]. Vascular surgery referral can be placed for any aortic aneurysm. Any incidence of ruptured aortic aneurysms requires emergent operative repair.

Surgical intervention is then further dened based on endovascular repair versus open repair. EVAR is the most common repair, but there are still cases in which open repair is preferred. Endovascular repair is dened as EVAR (endo­vascular aortic repair), TEVAR (thoracic endo­vascular repair), and FEVAR (fenestrated endovascular aortic repair).

Endovascular aortic repair is completed via percutaneous or open arterial access. Straightforward EVAR can be completed with procedural sedation versus general sedation. Open access may be indicated in patients with concomitant peripheral arterial disease, small access vessels, or prior surgical interventions. Depending on the complexity of the repair, alternative access sites may also be indicated including brachial artery or open axillary artery conduit. Repair is completed by placing a bifur­cated endograft within the aorta thereby exclud­ing the aneurysm sac (Fig. 28.5). Prior to completion, a nal angiogram is imaged to ensure no evidence of endoleak at the remainder of the case. Occasionally, assistive devices are used to aid with the seal zone including xation devices, coiling, or onyx glue in patients with a short neck.

Open aortic repair is completed via midline or retroperitoneal incision (Fig. 28.6). The extent of repair is based on anatomical involve­ment of iliac and femoral arteries or concomi­tant PAD. The incision is carried down to the abdominal cavity exposing the aorta. A retro­peritoneal approach is performed with the patient in right lateral decubitus position through a left ank incision. The proximal and distal arteries are then clamped, repair is completed