Table Of ContentDiffi cult Decisions in Surgery:
An Evidence-Based Approach
Christopher L. Skelly
Ross Milner Editors
Diffi cult
Decisions
in Vascular
Surgery
An Evidence-Based Approach
Difficult Decisions in Surgery: An Evidence-Based
Approach
Series editor
Mark K. Ferguson
Department of Surgery, MC5040
University of Chicago
Chicago, IL
USA
The complexity of decision making in any kind of surgery is growing exponentially.
As new technology is introduced, physicians from nonsurgical specialties offer
alternative and competing therapies for what was once the exclusive province of the
surgeon. In addition, there is increasing knowledge regarding the efficacy of
traditional surgical therapies. How to select among these varied and complex
approaches is becoming increasingly difficult. These multi-authored books will
contain brief chapters, each of which will be devoted to one or two specific questions
or decisions that are difficult or controversial. They are intended as current and
timely reference sources for practicing surgeons, surgeons in training, and educators
that describe the recommended ideal approach, rather than customary care, in
selected clinical situations.
More information about this series at http://www.springer.com/series/13361
Christopher L. Skelly • Ross Milner
Editors
Difficult Decisions in
Vascular Surgery
An Evidence-Based Approach
Editors
Christopher L. Skelly Ross Milner
The University of Chicago Medical Center The University of Chicago Medical Center
and Biological Science Division and Biological Science Division
Chicago, IL Chicago, IL
USA USA
ISSN 2198-7750 ISSN 2198-7769 (electronic)
Difficult Decisions in Surgery: An Evidence-Based Approach
ISBN 978-3-319-33291-8 ISBN 978-3-319-33293-2 (eBook)
DOI 10.1007/978-3-319-33293-2
Library of Congress Control Number: 2016963431
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Preface
Vascular surgeons are bound together through the shared experience of vascular surgi-
cal training. As surgical residents, we operate, we labor, we train, we study, we treat,
and we endure clinical challenges that shape and ultimately solidify our decision-mak-
ing skills as a natural extension of our selves. As surgeons who have to make snap
decisions because of life-threatening vascular emergencies, the skills of surgical deci-
sion making are a crucial talent to master. Over the course of the past three decades, the
endovascular era disrupted vascular surgery in a way that has changed the profession
forever. The endovascular innovation also disrupted the process of clinical decision
making. As a result, many surgeons who had trained in the pre-endovascular era were
faced with new tools and techniques that were not a natural extension of their clinical
training and therefore not a natural extension of themselves. A new level of complexity
was added to the snap decision-making process. Conversely, younger surgeons who
came into practice after the establishment of endovascular surgery may lack the open
approach skill set or the older tools to adequately include in their clinical decision
making. Clinical vascular decision making had effectively been changed forever.
The objectives of this book are to explain the process of decision making, both on
the part of the physician and on the part of the patient; to discuss specific clinical prob-
lems in vascular surgery; and to provide recommendations regarding their manage-
ment using. The Society for Vascular Surgery (SVS) recognized that clinical decision
making had been changed by the endovascular era and in 2006 published “Guideline
methodology of the Society for Vascular Surgery including the experience with the
GRADE framework.” With this guideline, the profession of vascular surgery effec-
tively entered the realm of evidence-based medicine to help guide vascular surgeons in
areas that they may be unfamiliar. This text is a natural extension of the SVS goal to
improve upon the process of clinical decision making for the practicing vascular sur-
geon and to ultimately improve patient outcomes. To accomplish this, it was necessary
to assemble a phalanx of authors widely felt to be experts in their fields. They were
given the assignment of crucially evaluating evidence on a well-defined topic: one
based solely on the existing evidence and another based on their prevailing practice,
clinical experience, and teaching. In addition to the analysis of the evidence on the
topic, we include a section in each chapter called: A personal view of the data. This
v
vi Preface
section allowed for the authors’ personal opinion of the data and the application to the
data. This component we found to complement the evidence perfectly because it allows
for the expression of the “art” in the “Art and Science of Medicine.” In other words, we
gave the author license to juxtapose any differences between practicing medicine
(the snap decisions based on practice) with research medicine (clinical trials).
This book is intended as a resource for clinical surgeons and other interested
readers who wish to understand how experts in the field assess existing knowledge.
As part of the process, authors were asked to assess the evidence quality based on
the following criteria.
High quality We are very confident that the true effect lies close to that of the estimate of the
effect
Moderate We are moderately confident in the estimate of effect: The true effect is likely to
quality be close to the estimate of effect, but possibility to be substantially different
Low quality Our confidence in the effect is limited: The true effect may be substantially
different from the estimate of the effect
Very low We have very little confidence in the effect estimate: The true effect is likely to
quality be substantially different from the estimate of effect
What became apparent in going through the process of editing this text was that
the quality of data upon which we base many of our decisions in vascular surgery is
low to moderate quality. Therefore, this book is not intended to be used as a clinical
pathway for management of our vascular surgical patients. As with all clinical care,
consideration must be given to the individual needs of patients in the context of that
physician–patient relationship.
My hope is that readers will find the information and recommendations in this
book insightful and intellectually stimulating. I encourage the readers who find a
particular chapter interesting to read the original source materials to come up with
their own objective conclusions. Furthermore, I encourage students and residents
and practicing surgeons to realize that there are gaps in our knowledge that can and
should be filled with good strong quality evidence.
Producing a book of this caliber in a relatively short time period requires the help
of a number of individuals. I would like to thank the students, residents, fellows, and
faculty with whom I work on a daily basis for stimulating discussions and the basis for
many of the chapters. I would like to thank the authors, co-authors, and their support
staff for all of the hard work required to produce this work and my continual pestering
and revisions. I am indebted to Michael Sova, Jessica Gonzalez, and Julia Megginson
at Springer for keeping my colleagues on track, ushering the manuscripts through to a
finished product. I thank my family for their continual patience and unquestioning
support. Finally, I am indebted to Mark Ferguson who was my teacher and now my
colleague, for his innovative approach to evidence-based medicine and shepherding
this concept through the profession of surgery as a whole. Dr. Ferguson has champi-
oned a movement away from the time honored traditional training format of “see one,
do one, teach one” which as he points out “stifles insight, objectivity and creativity.”
Chicago, IL, USA Christopher L. Skelly
Chicago, IL, USA Ross Milner
Contents
Part I Aortic Disease
1 In Patients with Acute Type B Aortic Dissection,
Do Current Operative Therapies Reduce Complications
Compared to Medical Management? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nadia Awad and Joseph Lombardi
2 In Patients with a Chronic Type B Dissection, Does Endovascular
Treatment Reduce Long Term Complications? . . . . . . . . . . . . . . . . . . . 13
Yana Etkin and Ronald M. Fairman
3 In Patients with a Retrograde Type A Aortic Dissection,
Does Treatment Like a Type B Aortic Dissection
Improve Outcomes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Reilly D. Hobbs, Prashanth Vallabhajosyula, and Wilson Y. Szeto
4 In Patients with Small AAA, Does Medical Therapy
Prevent Growth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Kenneth R. Ziegler and John A. Curci
5 Challenging AAA Neck Anatomy: Does the Fenestrated or
Snorkel/Chimney Technique Improve Mortality and Freedom
from Reintervention Relative to Open Repair? . . . . . . . . . . . . . . . . . . . 49
Brant W. Ullery and Jason T. Lee
6 In Patients Who Require Hypogastric Artery Coverage
to Treat an AAA with EVAR, Does Preservation Improve
Outcomes When Compared to Exclusion of the Vessel? . . . . . . . . . . . . 63
Sina Iranmanesh and Edward Y. Woo
7 In Patients with Aortic Graft Infections, Does EVAR Improve
Long Term Survival Compared to Open Graft Resection? . . . . . . . . . 77
M. J. E. van Rijn, E. V. Rouwet, S. ten Raa, J. M. Hendriks,
and H. J. M. Verhagen
vii
viii Contents
8 Does EVAR Improve Outcomes or Quality of Life
in Patients Unfit for Open Surgery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Tadaki M. Tomita and Andrew W. Hoel
9 In Patients with Type 2 Endoleaks Does Intervention
Reduce Aneurysm Related Morbidity and Mortality
Compared to Observation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Lisa Kang and Brian Funaki
10 Ruptured Abdominal Aortic Aneurysm Treated
with Endovascular Repair; Does Decompressive
Laparotomy Result in Improved Clinical Outcomes? . . . . . . . . . . . . . 113
Chandler A. Long, Veer Chahwala, and Ravi K. Veeraswamy
11 In a Patient with Blunt Traumatic Aortic Injury,
Does TEVAR Improve Survival Compared to Open
Repair or Expectant Management? . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Gerald R. Fortuna Jr. and Ali Azizzadeh
Part II Lower Extremity Arterial Disease
12 I n Patients with Aortoiliac Occlusive Disease, Does Endovascular
Repair Improve Outcomes When Compared to Open Repair? . . . . . 137
Michael S. Hong and William C. Pevec
13 I n Patients with Aortoiliac Occlusive Disease, Does
Extra-anatomic Bypass Improve Quality of Life
and Limb Salvage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
George E. Havelka and William H. Pearce
14 I n Patients with Critical Limb Ischemia Does Bypass
Improve Limb Salvage and Quality of Life
When Compared to Endovascular Revascularization? . . . . . . . . . . . . 163
Jeffrey J. Siracuse and Alik Farber
15 I n Patients with Limb-Threatening Ischemia Who Are Not
Candidates for Revascularization Do Non-operative Options
Improve Outcomes Compared to Amputation? . . . . . . . . . . . . . . . . . . 171
Craig Weinkauf and Joseph L. Mills Sr.
16 In the Patient with Profunda Artery Disease, Is Open
Revascularization Superior to Endovascular Repair
for Improving Rest Pain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Jordan R. Stern and Victor M. Bernhard
17 In Patients with Limb-Threatening Vascular Injuries,
Is There a Role of Prophylactic Fasciotomy to Reduce
Ischemic Injury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Melanie Hoehn, Megan Brenner, and Todd E. Rasmussen
Contents ix
18 In Patients with Popliteal Entrapment Syndrome,
Does Surgery Improve Quality of Life? . . . . . . . . . . . . . . . . . . . . . . . . 207
Rachel E. Heneghan and Niten Singh
Part III Mesenteric Disease
19 In Patients with Acute Mesenteric Ischemia Does
an Endovascular or Hybrid Approach Improve Morbidity
and Mortality Compared to Open Revascularization? . . . . . . . . . . . . 221
Mark Wyers and Fahad Shuja
20 Chronic Mesenteric Arterial Disease: Does an Endovascular/Hybrid
Approach Improve Morbidity and Mortality as Compared
to Open Revascularization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Aaron C. Baker and Gustavo S. Oderich
21 In Patients with Mesenteric Ischemia Is Single
Vessel Reconstruction Equivalent to Multiple
Vessel Revascularization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Omar C. Morcos and Tina R. Desai
22 In Patients with Celiac Artery Compression Syndrome,
Does Surgery Improve Quality of Life? . . . . . . . . . . . . . . . . . . . . . . . . 263
Grace Zee Mak
23 I n Patients with Superior Mesenteric Artery Syndrome,
Is Enteric Bypass Superior to Duodenal Mobilization? . . . . . . . . . . . 275
Monika A. Krezalek and John C. Alverdy
24 In Patients with Renovascular Hypertension Is There
a Role for Open or Endovascular Revascularization
Compared to Medical Management? . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Joie C. Dunn, Sung Wan Ham, and Fred A. Weaver
25 Does Endovascular Repair Reduce the Risk of Rupture Compared
to Open Repair in Splanchnic Artery Aneurysms? . . . . . . . . . . . . . . . 297
Benjamin J. Pearce
Part IV Cerebrovascular Disease
26 In Patients with Asymptomatic Carotid Artery Stenosis Does
Current Best Medical Management Reduce the Risk of Stroke
Compared to Intervention (Endarterectomy or Stent)? . . . . . . . . . . . 311
James R. Brorson
27 In Patients with Symptomatic Carotid Artery Stenosis Is
Endarterectomy Safer Than Carotid Stenting? . . . . . . . . . . . . . . . . . . 321
Benjamin Colvard and Wei Zhou
