The Retrograde Approach

In this episode of The Retrograde Approach, Yogi and Sam discuss open infrainguinal bypass and reconstruction.

In this episode Yogi and Sam discuss their approach to the assessment and management of patients presenting with popliteal artery aneurysms. Including both acute and elective presentations.

In this episode Dr Yogi Sivakumaran and Dr Sam Farah discuss how they prepare, plan and perform an endovascular aneurysm repair (EVAR).

General Principles

• Quality of the CT Scan
• 1mm slices
• If initial scan – scan thoracic, abdomen and lower limbs; allows for exclusion of aneurysmal disease elsewhere as well as if baseline status of the aortia prior to intervention
• Also allows planning if a fenestrated repair required 
• Centerline – images are not cross-sectional and end up with cross-sectional diameters 
• Narrow diameter of the elliptical cross-section more in keeping with the true diameter 
• Draw a diagram and compare with the rep and consultant’s plan – appreciation of the complexity of the case
• Date of the index scan
• Documentation calcification, dissection, thrombus and stenotic disease
• Site of the lowest renal artery
• Clock face of the renal arteries origin as well as the origin of the internal iliac arteries 
• Angulation of the aortic neck 
• Type of neck
• Straight, angulated (plan according to IFU), tapered (oversize on the basis of the diameter below the renal arteries), reverse tapered (careful to avoid oversizing), bulge and short
• Access vessels 
• Diameters and lengths (which will be discussed)
• Grafts chosen
• Talk to the reps re: planning books 

Pre-operative consideration

• In the era of an endovascular repair, a durable repair is desired 
• Patient’s age 
• Patient’s co-morbidities 
• Renal function, cardiac and respiratory history
• Life expectancy
• Fitness for GA vs. LA and Sedation 
• The patient better of with an open or endovascular management strategy
• Suitability for endovascular 
• Complex vs. Standard EVAR 

Imaging 

Renal artery position

• Lowest renal artery; accessory renal arteries 

Diameters

• Infrarenal aortic neck diameter (assess for infrarenal thrombus; aim < 25% of the circumference and <2mm thickness) – multiple across the length of the neck 
• Aneurysm sac diameter
• Aortic bifurcation diameter
• CIA proximal, mid and distal

Lengths

• Aortic neck length
• Length from lowest renal to aortic bifurcation (to ensure sure that there is enough length for the contralateral limb)
• Length from aortic bifurcation to iliac bifurcation

Angles

• Renal arteries origin off the aortic
• Internal iliac arteries origin off the bifurcation 
• Supra and infrarenal angulation if appropriate 

Access vessels

• Femoral/Iliac artery diameter 
• Tortuosity of the iliac arteries

Large lumbar vessels or inferior mesenteric artery >3mm 

In this episode, Yogi and Sam discuss the management of blunt thoracic injury and discuss difficult and challenging operative decisions.

In our third and final part in our review of the vascular exam in vascular surgery we discuss the clinical decision making viva, as well as the long case and the short cases.

In our second episode, Yogi and Sam take a deeper look into the fellowship exam looking specifically at the operative and imaging vivas. They reflect on the strategies and approaches they used to successfully navigate these challenging aspects of the examination.

In our first episode of The Retrograde Approach, Dr Yogi Sivakumaran and Mr Sam Farah embark on part one of a three part series discussing their recent reflections on completing the fellowship exam in vascular surgery in a year like no other.