Vascular Surgery

Arteriovenous (AV) Fistulas

Definition

An AV fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula is a surgically created anastomosis between an artery and a vein. This procedure is commonly performed for individuals with end-stage renal disease who require permanent vascular access for hemodialysis Hemodialysis Procedures which temporarily or permanently remedy insufficient cleansing of body fluids by the kidneys. Crush Syndrome, although it may also be congenital Congenital Chorioretinitis.

Indications

• CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease stage 5: defined by a GFR GFR The volume of water filtered out of plasma through glomerular capillary walls into Bowman’s capsules per unit of time. It is considered to be equivalent to inulin clearance. Kidney Function Tests < 30 mL/min
• Imminent need for dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• Venous occlusion
• Amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation
• Advanced peripheral artery disease Peripheral artery disease Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs. The disease can be a result of atherosclerosis or thrombosis. Patients may be asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. Peripheral Artery Disease with necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage on the side of AV fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula creation

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care: 

• Previous fast (nil per os (NPO)) for 8 hours
• Explain the procedure, benefits, risks, and alternatives to obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent.
• Labs:
  • Platelet count > 50,000
  • PTT and PT within acceptable ranges
• Required imaging: duplex ultrasonography Duplex ultrasonography Ultrasonography applying the doppler effect combined with real-time imaging. The real-time image is created by rapid movement of the ultrasound beam. A powerful advantage of this technique is the ability to estimate the velocity of flow from the doppler shift frequency. Hypercoagulable States
• Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are held before the procedure.
• Antibiotic prophylaxis Prophylaxis Cephalosporins before the procedure: 1st-generation cephalosporin Cephalosporin Multidrug-resistant Organisms and Nosocomial Infections ( cefazolin Cefazolin A semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. Cephalosporins)

In the OR:

• The individual is placed in the supine position.
• IV access is obtained.
• Continuous monitoring:
  • HR
  • Blood pressure
  • Oxygen saturation Oxygen Saturation Basic Procedures (pulse oximetry)
  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) rhythm monitor

Operative care:

• The most common AV fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula techniques include:
  • Radiocephalic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula
  • Brachiocephalic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula
  • Transposed brachiobasilic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula
• Recommended to perform this on the nondominant arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy 
• Access placed as distally as possible

Radiocephalic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula (Brescia-Cimino fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula):

1. A transverse incision is made in the wrist. 
2. The radial artery Radial Artery The direct continuation of the brachial trunk, originating at the bifurcation of the brachial artery opposite the neck of the radius. Its branches may be divided into three groups corresponding to the three regions in which the vessel is situated, the forearm, wrist, and hand. Forearm: Anatomy and cephalic vein are dissected.
3. An anterolateral arteriotomy is made on the radial artery Radial Artery The direct continuation of the brachial trunk, originating at the bifurcation of the brachial artery opposite the neck of the radius. Its branches may be divided into three groups corresponding to the three regions in which the vessel is situated, the forearm, wrist, and hand. Forearm: Anatomy, and a corresponding venotomy is made on the cephalic vein.
4. The 2 vessels are anastomosed using a nonabsorbable suture.

Brachiocephalic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula (Kaufmann fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula):

1. A transverse incision is made over the antecubital fossa Antecubital Fossa Molluscum Contagiosum.
2. The brachial artery Brachial Artery The continuation of the axillary artery; it branches into the radial and ulnar arteries. Cubital Fossa: Anatomy and cephalic vein are dissected.
3. Arteriotomy and venotomy are performed on each vessel.
4. The vessels are anastomosed using a nonabsorbable suture.

Transposed brachiobasilic fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula (2-stage approach):

1. A transverse incision is made distal to the antecubital fossa Antecubital Fossa Molluscum Contagiosum.
2. The brachial artery Brachial Artery The continuation of the axillary artery; it branches into the radial and ulnar arteries. Cubital Fossa: Anatomy and basilic vein Basilic vein Arm: Anatomy are dissected.
3. An arteriotomy is made in the distal brachial artery Brachial Artery The continuation of the axillary artery; it branches into the radial and ulnar arteries. Cubital Fossa: Anatomy.
4. The distal basilic vein Basilic vein Arm: Anatomy is ligated and divided, leaving a free end.
5. An end of the basilic vein Basilic vein Arm: Anatomy is anastomosed to the arteriotomy on the brachial artery Brachial Artery The continuation of the axillary artery; it branches into the radial and ulnar arteries. Cubital Fossa: Anatomy using nonabsorbable suture.

Final steps:

• Vascular Doppler Doppler Ultrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow. Ultrasound (Sonography) imaging is used to confirm patency.
• The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is closed by layers using nonabsorbable sutures Nonabsorbable Sutures Surgical Instruments and Sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or “brite” adipose tissue, which is a transitional form. Adipose Tissue: Histology).
• Sterile Sterile Basic Procedures gauze and a dressing are placed over the surgical wound. 
• The following are documented:
  • Hour of initiation
  • Hour of completion
  • Steps followed
  • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

Observation in the recovery room Recovery room Hospital unit providing continuous monitoring of the patient following anesthesia. Postoperative Care for 6 hours if necessary, or moved directly to the wards, according to each individual case.

Fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula maintenance:

• Monitoring during dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis sessions.
• Individuals can be taught to examine the fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula for a thrill (indicates patency). The fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula should also be evaluated by a physician with routine appointments.
• Ensure proper cleanliness and avoidance of clothing and jewelry over the access point to prevent flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure restriction.
• Bathing and everyday activities can be resumed as tolerated.

Complications

• Steal syndrome:
  • Blood entering the limb moves through the fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula without entering capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries: Histology. 
  • Clinical presentation: hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, coldness, sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and/or motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology dysfunction, cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination or pallor of the digits, and reduced or absent pulses,
  • Secondary to decreased blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure to the distal extremity
• Thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus
• Hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
• Hemorrhage
• Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
• Aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms/ pseudoaneurysm Pseudoaneurysm Not an aneurysm but a well-defined collection of blood and connective tissue outside the wall of a blood vessel or the heart. It is the containment of a ruptured blood vessel or heart, such as sealing a rupture of the left ventricle. False aneurysm is formed by organized thrombus and hematoma in surrounding tissue. Thoracic Aortic Aneurysms:
  • Common complication because of repetitive needle sticks during dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis
  • To avoid this complication, the needle should be inserted at different points in a rotating pattern.
• Fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula infection
• Central venous stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)
• Failure to mature: Most commonly due to anastomotic stricture Stricture Primary Sclerosing Cholangitis.

Thrombectomy/Embolectomy

Definition

Thrombectomy is an interventional procedure by which a blood clot or thrombus is surgically removed from a vessel via endovascular devices under imaging guidance.

Classification

• Pullback thrombectomy with a balloon catheter
• Aspiration (suction) thrombectomy
• Fragmentation Fragmentation Chronic Apophyseal Injury:
  • Recirculation thrombectomy: pulverizes the thrombus into microscopic fragments
  • Nonrecirculation thrombectomy: macerates the thrombus into macroscopic fragments
• Energy-assisted thrombectomy: uses ultrasound, laser, or radiofrequency to lyse the thrombus

Indications

• Stroke: injury undergone by brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tissue after interruption of blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure ( ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke) or active hemorrhage ( hemorrhagic stroke Hemorrhagic stroke Stroke due to rupture of a weakened blood vessel in the brain (e.g., cerebral hemispheres; cerebellum; subarachnoid space). Subarachnoid Hemorrhage) that has characteristic neurologic deficits Neurologic Deficits High-Risk Headaches
• MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: injury to the myocardium Myocardium The muscle tissue of the heart. It is composed of striated, involuntary muscle cells connected to form the contractile pump to generate blood flow. Heart: Anatomy due to ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage, characterized by an increase in cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes (especially troponin T), ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) changes suggestive of ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage in 2 contiguous leads, and chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. 
• Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism (PE): potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy or its branches by material (e.g., thrombus, air, amniotic fluid Amniotic fluid A clear, yellowish liquid that envelopes the fetus inside the sac of amnion. In the first trimester, it is likely a transudate of maternal or fetal plasma. In the second trimester, amniotic fluid derives primarily from fetal lung and kidney. Cells or substances in this fluid can be removed for prenatal diagnostic tests (amniocentesis). Placenta, Umbilical Cord, and Amniotic Cavity, or fat)

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• Intracranial hemorrhage Intracranial hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most sahs originate from a saccular aneurysm in the circle of willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage
• Large infarct Infarct Area of necrotic cells in an organ, arising mainly from hypoxia and ischemia Ischemic Cell Damage core with minimal penumbra
• Small-vessel occlusion
• Coagulopathies Coagulopathies Hemothorax
• Uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or “uncontrolled” hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care: 

• Dietary fast (nil per os (NPO)) for 8 hours.
• Explain the procedure, benefits, risks, and alternatives to obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent.
• Labs:
  • Platelet count > 50,000
  • PTT and PT within acceptable ranges
  • Renal function: serum creatinine and blood urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle within normal ranges.
  • HbA_1c
• Diagnostic images: ultrasound, head CT scan
• Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.

In the OR:

• The individual is placed in the supine position.
• IV access is obtained.
• Continuous monitoring:
  • HR
  • Blood pressure
  • O₂ saturation (pulse oximetry)
  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) rhythm monitor

Operative care:

There are several thrombectomy techniques. The following uses a balloon catheter and stent for thrombus removal. 

1. A balloon catheter is inserted through a groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination puncture. 
2. The catheter is advanced until it reaches the thrombus. 
3. A guidewire is advanced through the thrombus.
4. A microcatheter is passed over the guidewire and through the thrombus. 
5. A stent is deployed, and once it reaches the thrombus, it is deployed within the vessel.
6. The projections of the stent secure the thrombus to its surface. 
7. Contrast is injected through the balloon catheter to ensure patency of the vessel. 
8. The balloon is inflated to temporarily restrict flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure and allow removal of the stent with the thrombus and microcatheter.
9. Angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery is performed to check if the thrombus was completely removed.
10. The balloon catheter is removed. 

Final steps:

• Sterile Sterile Basic Procedures gauze and a dressing are placed over the puncture site.
• The following are documented:
  • Name of procedure
  • Hour of initiation
  • Hour of completion
  • Steps followed
  • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

• Observation in the recovery room Recovery room Hospital unit providing continuous monitoring of the patient following anesthesia. Postoperative Care for 6 hours; later moved to the wards. Individuals with neurologic conditions may need to be admitted to the neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery ICU ICU Hospital units providing continuous surveillance and care to acutely ill patients. West Nile Virus.
• Close monitoring of:
  • Blood pressure ( hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension → reperfusion injury Reperfusion injury Adverse functional, metabolic, or structural changes in ischemic tissues resulting from the restoration of blood flow to the tissue (reperfusion), including swelling; hemorrhage; necrosis; and damage from free radicals. The most common instance is myocardial reperfusion injury. Ischemic Cell Damage)
  • Temperature ( fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever)
  • Glycemia ( hyperglycemia Hyperglycemia Abnormally high blood glucose level. Diabetes Mellitus → worse clinical outcomes)
• Serial neurologic examination 

Complications

• Dislodging of embolic material
• Stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) at the thrombectomy site
• Vessel perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis or dissection
• Groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination/ retroperitoneal Retroperitoneal Peritoneum: Anatomy hematomas
• Reocclusion (due to thrombocytosis or preexisting stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS))

Peripheral Artery Bypass (PAB)

Definition

A PAB (also known as a peripheral vascular bypass) is a surgical procedure that uses a graft Graft A piece of living tissue that is surgically transplanted Organ Transplantation to restore perfusion to a segment of the arterial circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment distal to an occlusion. This procedure can be performed in potentially any segment of circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment.

Indications

• Peripheral artery disease Peripheral artery disease Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs. The disease can be a result of atherosclerosis or thrombosis. Patients may be asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. Peripheral Artery Disease (PAD): Obstruction of the arterial lumen, commonly secondary to atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis or thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus, that results in decreased blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure to visceral organs or the distal limbs. Individuals may initially be asymptomatic and later develop organ dysfunction, claudication, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions discoloration, ischemic ulcers, or gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction.
  • Narrowing in the heart is termed coronary artery Coronary Artery Truncus Arteriosus disease.
  • Narrowing in the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification is termed cerebrovascular disease.
  • Narrowing in the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy is termed renovascular disease.
  • Narrowing in the legs may cause leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with walking ( intermittent claudication Intermittent claudication A symptom complex characterized by pain and weakness in skeletal muscle group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial stenosis; muscle ischemia; and accumulation of lactate. Thromboangiitis Obliterans (Buerger’s Disease))
  • Smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases is the strongest risk factor for PAD
• Traumatic arterial injuries
• Aneurysms

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• History of cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery (e.g., stenting, angioplasty Angioplasty Reconstruction or repair of a blood vessel, which includes the widening of a pathological narrowing of an artery or vein by the removal of atheromatous plaque material and/or the endothelial lining as well, or by dilatation (balloon angioplasty) to compress an atheroma. Except for endarterectomy, usually these procedures are performed via catheterization as minimally invasive endovascular procedures. Cardiac Surgery or coronary artery Coronary Artery Truncus Arteriosus bypass) 
• Respiratory disease (e.g., chronic obstructive pulmonary disease Pulmonary disease Diseases involving the respiratory system. Blastomyces/Blastomycosis)

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care:

• Dietary fast (nil per os (NPO)) for 8 hours
• Explain the procedure and obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent.
• Labs:
  • Platelet count > 50,000
  • Adequate hemoglobin and hematocrit Hematocrit The volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value. Neonatal Polycythemia
  • PTT and PT within acceptable ranges
  • Blood type, cross, and match
  • Renal function: serum creatinine and BUN within normal ranges (unless performing renovascular intervention).
  • HbA_1c
• Required imaging: ultrasonography
• These procedures may involve significant blood loss requiring transfusion. Blood products are made available for transfusion after blood type is obtained.
• Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.
• Antibiotic prophylaxis Prophylaxis Cephalosporins within 1 hour before the procedure: 1st-generation cephalosporin Cephalosporin Multidrug-resistant Organisms and Nosocomial Infections ( cefazolin Cefazolin A semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. Cephalosporins) 

In the OR:

• The individual is placed in the supine position.
• IV access is obtained.
• Continuous monitoring:
  • HR
  • Blood pressure
  • O₂ saturation (pulse oximetry)
  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) rhythm monitor

Operative care:

The procedure itself will vary widely depending on the surgical anatomy and location of the obstruction. However, the underlying principle of PAB is establishing proximal and distal anastomoses in disease-free segments. Some examples of PAB include:

1. Iliofemoral bypass: ipsilateral or contralateral iliac artery is communicated with the common femoral artery Femoral Artery The main artery of the thigh, a continuation of the external iliac artery. Femoral Region and Hernias: Anatomy (CFA)
2. Aortobifemoral bypass: the abdominal aorta Abdominal Aorta The aorta from the diaphragm to the bifurcation into the right and left common iliac arteries. Posterior Abdominal Wall: Anatomy is communicated with both CFAs
3. Femoropopliteal bypass: the popliteal artery Popliteal Artery The continuation of the femoral artery coursing through the popliteal fossa; it divides into the anterior and posterior tibial arteries. Popliteal Fossa: Anatomy is communicated with a single femoral artery Femoral Artery The main artery of the thigh, a continuation of the external iliac artery. Femoral Region and Hernias: Anatomy

Grafts are created with organic (e.g., harvested saphenous vein) or artificial (e.g., polytetrafluoroethylene) materials. 

Final steps:

• The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is closed by layers using nonabsorbable sutures Nonabsorbable Sutures Surgical Instruments and Sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or “brite” adipose tissue, which is a transitional form. Adipose Tissue: Histology).
• Sterile Sterile Basic Procedures gauze and a dressing are placed over the surgical wound. 
• The following are documented:
  • Name of procedure
  • Hour of initiation
  • Hour of completion
  • Steps followed
  • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

• Observation in recovery room Recovery room Hospital unit providing continuous monitoring of the patient following anesthesia. Postoperative Care for 6 hours; later moved to the wards
• Physical examination:
  • Vascular: reduced pulses, prolonged capillary filling time, hematomas
  • Neurologic: paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Posterior Cord Syndrome, paralysis

Complications

• Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications ( SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections): A type of infection that occurs at or near a surgical incision Surgical Incision Surgical Site Infections within 30 days after the procedure or within 90 days if prosthetic material is implanted. An SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections is classified according to the depth of compromise—superficial, deep, or organ/space.
• Hemorrhage/ hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
• Aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms/ pseudoaneurysm Pseudoaneurysm Not an aneurysm but a well-defined collection of blood and connective tissue outside the wall of a blood vessel or the heart. It is the containment of a ruptured blood vessel or heart, such as sealing a rupture of the left ventricle. False aneurysm is formed by organized thrombus and hematoma in surrounding tissue. Thoracic Aortic Aneurysms
• Failure of anastomoses
• Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
• Graft Graft A piece of living tissue that is surgically transplanted Organ Transplantation occlusion
• Neighboring nerve injury Nerve Injury Surgical Complications

Carotid Endarterectomy (CEA)

Definition

A CEA CEA A glycoprotein that is secreted into the luminal surface of the epithelia in the gastrointestinal tract. It is found in the feces and pancreaticobiliary secretions and is used to monitor the response to colon cancer treatment. Serum Tumor Markers is a surgical procedure in which atherosclerotic plaque Plaque Primary Skin Lesions is manually removed from the common and/or internal carotid artery Internal carotid artery Branch of the common carotid artery which supplies the anterior part of the brain, the eye and its appendages, the forehead and nose. Carotid Arterial System: Anatomy. The therapeutic goals are to restore normal blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure and reduce the likelihood of embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding.

Indications

• Carotid artery stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) (> 50% stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)) and symptoms
• Asymptomatic individuals with carotid stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) > 60%
• History of ipsilateral stroke or transient ischemic attack Transient ischemic attack Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA) ( TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA))

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• Very ill and symptomatic individuals who are unable to undergo an open surgical procedure
• History of radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma therapy to the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
• Individuals with high-likelihood of poor outcomes must be carefully selected.
  • Older age (> 70 years)
  • Severe heart disease
  • Severe pulmonary dysfunction
  • Renal insufficiency or failure
  • Stroke as the indication for endarterectomy Endarterectomy Surgical excision, performed under general anesthesia, of the atheromatous tunica intima of an artery. When reconstruction of an artery is performed as an endovascular procedure through a catheter, it is called atherectomy. Intestinal Ischemia

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care: 

• Dietary fast (nil per os (NPO)) of 8 hours
• Explain the procedure and obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent.
• Labs:
  • Platelet count > 50,000
  • PTT and PT within acceptable ranges
  • Renal function: serum creatinine and blood urea Urea A compound formed in the liver from ammonia produced by the deamination of amino acids. It is the principal end product of protein catabolism and constitutes about one half of the total urinary solids. Urea Cycle nitrogen Nitrogen An element with the atomic symbol n, atomic number 7, and atomic weight [14. 00643; 14. 00728]. Nitrogen exists as a diatomic gas and makes up about 78% of the earth’s atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. Urea Cycle within normal ranges
  • HbA_1c
• Required images: carotid duplex ultrasonogram; head CT scan
• Antiplatelet therapy with aspirin Aspirin The prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Nonsteroidal Antiinflammatory Drugs (NSAIDs) (81–325 mg/day) prior to the procedure 
• Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld if so indicated by the surgeon.
• Antibiotic prophylaxis Prophylaxis Cephalosporins within 1 hour before the procedure: 1st-generation cephalosporin Cephalosporin Multidrug-resistant Organisms and Nosocomial Infections ( cefazolin Cefazolin A semisynthetic cephalosporin analog with broad-spectrum antibiotic action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. Cephalosporins)

In the OR:

• The individual is placed in the supine position.
• IV access is obtained.

• Continuous monitoring:
  • HR
  • Blood pressure
  • O₂ saturation (pulse oximetry)
  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) rhythm monitor
• The individual can be placed under general or local anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts with sedation.

Operative care:

1. An incision is made alongside the medial border of the sternocleidomastoid Sternocleidomastoid Muscles of the Neck: Anatomy muscle.
2. The platysma Platysma Muscles of the Neck: Anatomy muscle and soft tissues are dissected until the carotid sheath is reached. 
3. The carotid sheath is incised carefully and the carotid artery is exposed. 
4. The compromised artery is clamped proximally and distally to the plaque Plaque Primary Skin Lesions. 
5. An arteriotomy is performed on the vessel, and surgery progresses until both ends of the plaque Plaque Primary Skin Lesions are reached. 
6. The plaque Plaque Primary Skin Lesions is removed from the vessel (the vessel wall may be everted around the plaque Plaque Primary Skin Lesions). 
7. The arterial wall is repaired with a patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes that will widen the vessel lumen. The patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes can be of organic (e.g., vein, bovine patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes) or synthetic (Dacron) material.

Final steps:

• The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is closed by layers using nonabsorbable sutures Nonabsorbable Sutures Surgical Instruments and Sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or “brite” adipose tissue, which is a transitional form. Adipose Tissue: Histology).
• Sterile Sterile Basic Procedures gauze and a dressing are placed over the surgical wound. 
• The following are documented:
  • Name of procedure
  • Hour of initiation
  • Hour of completion
  • Steps followed
  • Complications encountered

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care:

• Observation in recovery room Recovery room Hospital unit providing continuous monitoring of the patient following anesthesia. Postoperative Care for 6 hours; later moved to the wards
• Neurologic examination every hour.
• Blood pressure control ( hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension → neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception)

Complications

• Hemorrhage
• Neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
• Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications
• Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
• MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
• Cerebral hyperperfusion syndrome: A clinical presentation secondary to increased cerebral perfusion Cerebral Perfusion Syncope after carotid endarterectomy Endarterectomy Surgical excision, performed under general anesthesia, of the atheromatous tunica intima of an artery. When reconstruction of an artery is performed as an endovascular procedure through a catheter, it is called atherectomy. Intestinal Ischemia that is characterized by ipsilateral headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, and focal neurological deficits Focal Neurological Deficits Brain Abscess. If not treated, cerebral hyperperfusion can result in severe cerebral edema Cerebral edema Increased intracellular or extracellular fluid in brain tissue. Cytotoxic brain edema (swelling due to increased intracellular fluid) is indicative of a disturbance in cell metabolism, and is commonly associated with hypoxic or ischemic injuries. An increase in extracellular fluid may be caused by increased brain capillary permeability (vasogenic edema), an osmotic gradient, local blockages in interstitial fluid pathways, or by obstruction of CSF flow (e.g., obstructive hydrocephalus). Increased Intracranial Pressure (ICP) or intracerebral or subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage.
• Greater auricular nerve injury Nerve Injury Surgical Complications
• Cranial nerve injury Nerve Injury Surgical Complications (hypoglossal, vagus, glossopharyngeal, and facial)
• Perioperative stroke and TIA TIA Transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without infarction that resolves completely when blood supply is restored. Transient ischemic attack is a neurologic emergency that warrants urgent medical attention. Transient Ischemic Attack (TIA)