The Retrograde Approach

Episode 27: Transitioning to life as a consultant

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 18 Sep 2023 07:00:00 +1000

In our first non technical episode we discuss changes in life from going from trainee surgeon, to surgeon.

Episode 26: Thoracic Aortic Stenting

Dr Sam Farah and Dr Yogeesan Sivakumaran — Thu, 01 Jun 2023 21:00:00 +1000

In this episode, Yogi and Sam delve into discussing thoracic aortic stenting.

Podcast 26 - Thoracic Aortic Stenting

The first endovascular thoracic aneurysm repair was performed by Dale in 1994 - with the use of custom designed graft with a combination go Gianturco Z-stents and polyester fabric. It was not till 2005 that a commercially available thoracic graft became available

The introduction of TEVAR has added further dimensions to open surgery by creating treatment options not previously available in treating aortic dissection, thoracic and thoracoabdominal aneurysm and traumatic injury.

In elderly patients, TEVAR has replaced open surgery and medical management for problems confined to the descending thoracic aorta

Indications

Aneurysmal disease (>5.5cm) - true degenerative aneurysms vs. post dissection aneurysms vs. mycotic vs. pseudo aneurysms (Zone 2)
Complicated acute aortic syndromes
Blunt thoracic aortic injury
Evolving techniques - management of dissection aneurysms in Zone 0/1

Approved Devices

Gore TAG Conformable Thoracic Stent Graft
Medtronic Valiant Thoracic Stent Graft with Captivia Delivery System
Cook Zenith Alpha
Endospan Nexus and Bolton
Terumo Aortic Relay Device

Pre-operative Considerations

How do we do it?

General consideration -
vascular access, iliac vessel diameters
For suitable iliac and femoral access vessels are required
Small diameters <7mm, existing calcification and vessel tortuosity have a profound impact on the procedure especially if present in combination
The right femoral artery is typically favoured for device insertion, whereas the contralateral femoral artery is reserved for diagnostic imaging
An ideal access vessel should be >7mm in diameter to accommodate a 22Fr sheath and >8mm for a 24 Fr sheath
Alternate options - iliac conduits or endo-paving
Landing zone
General role >20mm of normal appearing aorta for an adequate seal zone - proximal and distal
Longer seal zones is considered adequate for most cases, longer seal zones are preferable in angulated aortic segments to decrease the occurrence of Type 1 end-leaks and device migrations
Anatomical boundaries include the left subclavian artery and the coeliac artery should be considered a
Proximal and distal aortic diameters
Ishimaru’s Classification of Landing Zone
Coverage of the left subclavian artery is generally well tolerated because of a rich collateral network - however routine exclusion should be discouraged because experimental and clinical evidence suggest that not all patients tolerate the occlusion safely
The left subclavian artery is vital for perfusion of both the spinal cord and the brain via the left vertebral artery through the internal management and anterior intercostal branches
When left subclavian coverage is considered, pre-operative CTA imaging should assess latency of the right vertebral artery, connections to the Basilian artery and the COW in order to identify patients that may not tolerate left SCA occlusion
As we approach Zone 0,1 or sometimes in 2 supra-aortic debranching may be necessary
Open CTS vs. CCA-CCA-SCA, CCA- SCA, chimney stents
Imaging
CTA with fine slices
Sizing
Overzealous device sizing is associated with graft infolding, gutter formation and aortic neck degeneration due to excessive radial force \
Aortic diameters are measured with orthogonal reconstructions especially in areas of tortuosity and angulation
Neck diameters between the proximal and distal sealing zones can vary
A 10 to 20% oversizing at the proximal landing zone is recommended; less for dissection
Adjunctive Measures for Neuroprotection
Patients with long segment descending thoracic aortic coverage (>150mm), antecedent or concomitant abdominal aortic repair or bilateral internal iliac artery occlusions are at particularly high risk of spinal cord ischaemia
Staging procedures
Selective segmental artery coil embolisation
Intra-operative monitorings - Near infra-red spectroscopy monitoring, transcranial doppler and EEG
Identifying a threshold value with NIRS that correlates to cerebral ischaemia has been poor and it only gives information regarding the status of the frontal lobes
Spinal Drain
Elevated Blood Pressure, MAP > 90mmHg —. Can increase to 100mmHg if neurologic deficits are noted
Hb > 100
Oxygen supplementation

Procedure

Percutaneous femoral artery access
Typically up the right for the graft
Small access on the contralateral side for insertion of a diagnostic pigtail catheter
After access is established, a stiff guide wire is advanced into the ascending aorta; curved 260cm Lunderquist Wire and positioned such that the apex of the curve rests against the aortic valve
The end of the wire should be marked and efforts made to ensure that the wire stays in this position
Arch aortogram is performed via a pigtail catheter with a LAO of 30 to 60 degrees - the angle should be determined based on the pre-operative CTA
Air is then flushed from the system - ensure no air in the line; can be done by winding back into the pump or under water
Induction of temporary apnoea necessary
The endograft is introduced and advanced under fluoroscopic guidance
Typically the endograft is advanced past the proximal landing zone and drawn back to eliminated stored energy
Steady integrate pressure on the wire keeps the device positioned against the outer aortic wall for accurate deployment - stent grafts conform to the outer curvature of the thoracic aorta which can cause the graft to jump distally
Forward pressure on the Lunderquist wire will help push the wire against the outer curvature to better approximate the true path of the stent graft during deployment
The pressure can also help the apposition of the graft to the vessel wall, avoiding the “bird-beaking” effect
Acute angles in the descending thoracic aorta may render device tracking difficult - put the graft at risk of Type 1 endoleak and bird bearing
“Body flossing” - brachiofemoral access wires can help straighten the most angulated of vessels
When more than one TEVAR device is required, the smallest diameter device should be deployed first; for large proximal aortic aneurysms, with distal thoracic aortic tortuosity deploying the distal endograft first is preferable as it stabilises the proximal endograft and improves deployment accuracy
Proximal TEVAR deployments benefit from temporary reduction of mean arterial pressure which minimises the windsock effect and potential endograft migration
Strategies - administration of vasodilators, adenosine induced cardiac asystole, rapid cardiac pacing, sustained Valsalva manoeuvre, IVC balloon occlusion
Ongoing aortic blood flow can become trapped in the deploying graft graft and displace the stent distally, in a phenomenon known as the “windsock” effect
Graft molding is generally avoided in the setting of treatment for aortic dissection due to the risk of causing retrograde dissection - in aneurysmal disease, a non-compliant balloon can be used k
Completion angiogram

Complications

Mortality - early experience with first and second generation endografts in high risk individuals was associated with a high clearly mortality (9 to 12%); trials with third generation devices reported a 30 day mortality of 1 to 2.2% which is significantly lower than the 7% mortality associated with open surgical repair
Stroke - 3 to 8%
Presence of mobile atheroma, prior stroke, deployment of TEVAR proximal to the left CCA, air or plaque embolisation
Paraplegia
Peripheral Vascular Complications - embolism, thrombosis and vascular trauma
Vascular access complications due to large bore sheaths placed in atherosclerotic arteries were relatively high in the early trials but lower in follow up trials (~6%)
Aortic dissection
Aneurysm Sac Enlargement
Stent graft migration or fracture
Late migration < 0.7 to 3.9% - can occur at either end; predisposing factors for device migration include excessive endograft oversizing, tortuous seal zone anatomy and aortic elongation
Endoleak

Reasons for Spinal Drain

Length of coverage > 20cm
Coverage in the region of the artery of Adamweikz
Previous infrarenal aortic repair
Bilateral internal iliac artery atherosclerotic
Coverage of the left subclavian artery

However spinal drains are not without complications - that can arise during and/or after CSF drain insertion including catheter fracture, post dural puncture headache, neuroaxial haematoma, intracranial haemorrhage and meningitis

Complications associated with left subclavian artery coverage during TEVAR

Stroke - students have demonstrated a high overall stroke rate and posterior circulation stroke with intentional coverage of the left subclavian artery compared with left subclavian artery revascularisation
Spinal cord ischaemia / long term - chronic symptoms (claudication)
Left upper extremity ischaemia

Reasons for left subclavian artery revascularisation

Patent left arm arteriovenous shunt for dialysis
Presence of a patent left internal mammary to coronary artery bypass graft
Absent, atretic or occluded right vertebral artery
A dominant left vertebral artery is present in > 60% of patients; intuitively these anatomic findings place patients at increased risk for posterior circulation infarction if covered
Termination of the left vertebral artery into the posterior inferior cerebellar artery
Prior infrarenal aortic operation with previously ligated lumbar and middle sacral arteries
Planned extensive (>20cm) coverage of the descending thoracic aorta
Hypogastric artery occlusion
Presence of early aneurysmal disease where future therapy involving the distal thoracic aorta may be necessary
Anomalous origin of the left vertebral artery from the aortic arch

Anatomy of the Spinal Cord Circulation

Arterial supply
Anterior spinal artery which arises off the vertebral arteries
Prior to becoming the basilar artery, the vertebral arteries give off branches that become the anterior spinal artery which then passes down the anterior sulcus of the vertebral column
Posterior spinal arteries which arise off the posterior inferior cerebellar arteries and travel down caudally
Mid cervical cord receives blood supply via the segmental spinal arteries directly off the vertebral arteries
The lower cervical and upper thoracic cord receives blood supply via the radiculomedullary branches arising from the cervicothoracic trunk
Intercostal artery branches which give off segmental spinal arteries which supply the mid thoracic segment
The largest segmental spinal artery branch being the Artery of Adamkiewicz which arises from T8 to L2
Branches of the internal iliac artery supply the lumbosacral segment

Episode 25: Best CLI

Dr Sam Farah and Dr Yogeesan Sivakumaran — Tue, 07 Feb 2023 11:00:00 +1000

In this episode, Yogi and Sam unpack and explore the highly anticipated Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia (Best CLI) publication. This study has sought to clarify questions that had been raised in regards to the optimal treatment of chronic limb threatening ischaemia in the era of modern endovascular treatment.

https://www.nejm.org/doi/full/10.1056/NEJMoa2207899

Episode 24: Reflections of the Vascular Surgery Fellowship Exam 2022 feat. Dr Vikram Iyer

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 18 Jan 2023 07:00:00 +1000

In this episode we discuss the recent sitting of the vascular surgery fellowship exam with Dr Vikram Iyer. He shares his experiences and reflections on getting through the final hurdle before becoming a fully qualified vascular surgeon.

Episode 23: Peripheral Arterial Disease

Dr Sam Farah and Dr Yogeesan Sivakumaran — Sat, 17 Sep 2022 21:00:00 +1000

In this episode of The Retrograde Approach, Sam and Yogi take an introductory look at peripheral arterial disease.

Episode 22: Balancing research and clinical careers feat. Dr Leonard Shan

Dr Sam Farah and Dr Yogeesan Sivakumaran — Tue, 28 Jun 2022 07:00:00 +1000

In this weeks episode, we are joined by Dr Leonard Shan. A vascular surgeon working at St Vincent's hospital in Melbourne. Dr Shan is currently completing a PhD through the University of Melbourne, and joins us to talk today about balancing his busy research career, with his professional career and his home life.

Dr Shan is an academic vascular surgeon and honorary senior fellow in the Department of Surgery at The University of Melbourne. He received his medical education at The University of Melbourne where he graduated with honours. Following vascular surgical training at multiple centres in Melbourne and Auckland, he joined the vascular staff at St. Vincent’s Hospital in 2020.

His academic interest is in outcomes research where he has helped to improve the understanding of patient- reported outcomes after intervention. He serves on the editorial board of the Annals of Vascular Surgery and is a regular reviewer for the European Journal of Vascular and Endovascular Surgery and the Journal of Vascular Surgery. Leonard is currently undertaking a PhD on the patient-reported outcomes and economic evaluation of arterial surgery with Professor Peter Choong at The University of Melbourne, where he is the recipient of an Australian Government Research Training Program scholarship.

Episode 21: Arteriovenous Fistula - The Basics

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 01 Jun 2022 21:00:00 +1000

In this episode, we aim to give a basic overview to arteriovenous fistula's for dialysis access. Although, we could spend hours discussing AVFs - we have attempted to provide a general overview for those new to the concepts.

Episode 20: The Diabetic Foot

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 20 Apr 2022 07:00:00 +1000

In this episode, Yogi and Sam provide an overview into foot disorders within diabetic patients.

Episode 19: Asymptomatic Carotid Artery Disease

Dr Sam Farah and Dr Yogeesan Sivakumaran — Tue, 08 Feb 2022 07:00:00 +1000

In this episode we delve into the interesting world of carotid artery disease and discuss our management of patients who are asymptomatic. See Yogi's (amazing) crib notes below:

Why do we care about asymptomatic carotid artery disease?

About 10 to 15% of all first ever stroke patients will experience an unheralded ischaemic, carotid territory stroke following thromboembolism from a previously untreated asymptomatic significant carotid disease

Oxford Vascular Study

Enrolled 2354 consecutive patients including 207 with 50 to 99% carotid stenosis
The ipsilateral stroke rate at 5 years for the patients with 70% to 99% was 14.6% compared with 0% for 50 to < 70%
For patients with 80 to 99% carotid stenosis, the ipsilateral stroke was significantly greater than that for those with 50% to <80% stenosis

ACSRS Study

In ACAS and risk of stroke, there was an S-shaped relationship between the severity of stenosis and the incidence of ipsilateral TIA or stroke, such that the event rate for 50 to 69% stenosis were 8.2%, for 70 to 89% were 10.7% and for 90 to 99% were 19.3%
Progression of carotid stenosis is associated with an increased risk of stroke - patients with progression of carotid stenosis had two times the rate of ipsilateral stroke compared to patients without progression

Prevalence of ACAS

Four Population Based Cohort Studies (Malmo Diet and Cancer Study, Tromso Study, Carotid Atherosclerosis Progression Study and Cardiovascular Health Study)
Prevalence of asymptomatic moderate (>50%) and severe (>70%) stenoses in a population of 23,706 people (mean age of 61 years, 46% male) was 2.0% and 0.5% respectively
Moderate stenosis > 50% found in 4.8% of men and 2.2% of women younger than 70 years
The percentage increase to 12.5% in men and 6.9% in women if patients older than 70 years are considered

Severe asymptomatic stenosis (>70%) indicate that its prevalence ranges from 0% to 3.1% of general population

Seminal Trials

Seminal trials have demonstrated a marginal but definitive benefit for CEA in reducing the risk of stroke after 5 and 10 years when compared with “best medical therapy” alone. However, these studies conducted in the late 1980s and in the 1990s, and since their completion, progress in the medical management of cardiovascular diseases has led to a progressive decrease in the yearly risk of stroke in patients with asymptomatic carotid artery stenosis managed with medical treatment alone.

Veterans Affairs Cooperative Study (VACS) [1983 and 1987]

440 men with asymptomatic >50% carotid stenosis were randomised to CEA plus medical management versus medical management only CEA significantly reduced the combined incidence of ipsilateral neurologic events (stroke or TIA) compared to medical group (8.0% vs. 20.6% respectively)

ACAS

1662 patients with asymptomatic >60% carotid stenosis were randomised to medical therapy versus CEA plus medical therapy
Across the United States and Canada
The study was stopped early, after a median follow up of 2.7 years
Patients in the surgical arm had a 5.1% risk of ipsilateral stroke and preoperative stroke/death over 5 years versus 11.0% risk of ipsilateral stroke in the medical arm for a relative risk reduction of 53%; absolute risk reduction of 5.9%
Recommended CEA for patients aged < 80 years as long as the expected combined stroke and mortality rate for the individual surgeon as not > 3%

ACST-1

3120 patients with asymptomatic >60% carotid stenosis were randomised to either immediate CEA or deferred CEA
Asymptomatic patients were considered those without neurological symptoms during the 6 months preceding enrolment
Patients in the immediate CEA group had a significantly reduced five year and 10 year risk of any stroke and peri-operative stroke/death than the deferred CEA group (5 year, 6.9% vs. 10.9%, 10 year 13.4% vs. 17.9%)
An absolute risk reduction of 5.4% was seen in the rate of any stroke and peri-operative events when comparing immediate versus deferred surgery (6.4% vs. 11.8%)
There was also a significant difference in the risk of carotid territory stroke and fatal or disabling stroke between both groups
The overall peri-operative stroke and death rate in this study was 3.1%
The long-term effectiveness of CEA for asymptomatic patients was confirmed by the long-term results of ACST The 10 year data from ACST
10 year risk of any stroke and peri-operative events was 13.4% in the CEA group and 17.9% in the medical arm, representing an absolute risk reduction

Although CEA reduced the risk of stroke in patients with asymptomatic carotid stenosis in these trials, the absolute risk reduction from was only 5%

It is often said that ACAS and ACST reported a similar overall stroke risk reduction favouring CEA, but this is not true. A fundamental difference between the two studies is the primary end point: ipsilateral stroke in ACAS and any territory stroke in ACST.

Medical therapy in randomised trial

VACS - 650mg of Aspirin was taken by 55% of patients while 27% took lower doses. Antihypertensive therapy was less commonly used in VACS and no patient received statins
During ACAS/ACST-1, the use of BP and antithrombotic treatment increased
ACST-1 and ACAS included patients who took vibrates and statins, although ACTS-1 had longer follow up and more robust evidence about statin use (13% ACAS patients were on lipid-lowering therapy at entry vs. 32% in ACST-1)

When the stroke rate of patients receiving lipid lowering medications in the ACST trial was analysed, the patients who had undergone CEA with lipid lowering medication had a lower stroke incidence compared with the medical therapy arm. However the effect of CEA was not as great (0.7% vs. 1.3%) for those receiving lipid lowering therapy compared with 1.8% vs. 3.3% annually for those not receiving lipid lowering therapy.

Approximately half of the peri-operative strokes in CEA patients randomised within VACS and ACAS followed angiography. Overall VACS observed no difference in “ipsilateral” or “any” stroke at 4 years. By contrast, ACAS and ACST observed that CEA conferred significant reductions in “any”stroke while ACAS reported that CEA significantly reduced the 5 year rate of “ipsilateral” stroke.

The ACAS and ACST trials are pivotal in developing international practice guidelines, most of which advise that CEA should be performed with a 30 day death/stroke < 3% and that the patient should have a predicted survival > 5 years

Whose is at a higher risk of stroke on medical therapy?

AHA repeatedly has advised that only “highly selected” asymptomatic patients should undergo CEA
ACST - at 10 years, only 46 strokes will be prevented at 5 years per 1000 CEAs. This along with evidence that the annual risk of stroke on BMT may be declining, suggests that there is a need to develop clinical / imaging algorithms for identifying a smaller, but higher risk for stroke cohort in whom CEA/CAS might be targeted

Presence of one or more clinical and/or imaging features such as silent infarction on CT/MRI, stenosis progression, large plaque area, large juxta-luminal black area (JBA) on computerised plaque analysis, plaque echolucency, intra-plaque haemorrhage on MRI, impaired cerebral vascular reserve (CVR), and spontaneous embolisation on transcranial Doppler (TCD) monitoring, might be useful for selecting “higher-risk for stroke” patients for revascularisation

CAS vs CEA for ACAS

Five RCTs have published outcomes comparing CEA with CAS in “average risk for CEA” patients

Lexington, Mannheim, SPACE-2 and ACT-1 randomised asymptomatic patients from the outset
CREST-1 - originally a symptomatic RCT but a protocol change enabled them to randomise asymptomatic patients because of sluggish recruitment

A meta-analysis of data from four out of the five RCTs observed a 30 day death/stroke rate of 1.6% after CEA versus 2.7% after CAS.

In the Lexington RCT, no strokes or recurrent stenoses were reported at 4 years.

In CREST-1, the 4 year rate of ipsilateral stroke was 8% following CAS versus 6.7% after CEA. Re-stenosis (>70%) was 6.7% at 4 years after CAS and 6.2% after CEA.

In ACT-1, including peri-operative stroke/death/MI, the 1 year rate of ipsilateral stroke was 3.8% after CAS versus 3.4% after CEA.

The 5 year rate of ipsilateral stroke was 2.2% after CAS and 2.7% after CEA
The 5 year rate of “any” stroke was 6.9% after CAS versus 5.3% after CEA

SPACE 2 stopped in 2015

30 day stroke/death rate was 1.97% in 203 patients randomised to CEA vs. 2.54% in 197 patients randomised to CAS

Mannheim RCT

No late strokes at a mean follow up at 26 months
4.4% developed a 70 to 99% re-stenosis versus 1.5% after CAS

“High Risk” for Surgery Patients

SAPPHIRE study

Randomised 334 patients deemed “high risk for CEA” to either CEA or CAS
Criteria for defining a high risk for CEA” asymptomatic patient included an asymptomatic 70 to 99% stenosis in the presence of one or more of the following: clinically significant cardiac disease (CHF, abnormal stress test or need for open heart surgery), severe pulmonary disease, contralateral carotid occlusion, contralateral laryngeal nerve palsy, previous radical neck surgery, cervical radiation therapy, recurrent stenosis after CEA and age > 80 years
The majority of SAPPHIRE patients were asymptomatic (70%) - in whom 30 day death/stroke was 5.8% after CAS and 6.1% after CEA
At these levels of risk, none would gain benefit in terms of late stroke prevention - suggesting they should be treated medically

Carotid stenting may be considered in selected asymptomatic patients who have been deemed by MDT to be “high risk for surgery” and who have an asymptomatic 60 to 99% in the presence of one or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke, provided documented procedural risks are <3% and the patient’s life expectancy exceeds 5 years

Episode 18: Thoracic Outlet Syndrome feat. Dr Gert Frahm-Jensen

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 06 Dec 2021 07:30:00 +1000

In this exciting episode we are joined by Dr Gert Frahm-Jensen, who is an Australian trained Vascular and Endovascular Surgeon working in the Australian Capital Territory. After attaining his medical degree from the Australian National University he completed specialist training in vascular surgery throughout Victoria, Queensland and the ACT. He has a special interest in the management of thoracic outlet syndrome, and we are very appreciative of his expertise that he shares with us in this episode.

Episode 17: Early Career Development feat. Dr Nedal Katib

Dr Sam Farah and Dr Yogeesan Sivakumaran — Tue, 05 Oct 2021 07:00:00 +1000

This episode of The Retrograde Approach is proudly supported by The Australian and New Zealand Society for Vascular Surgery (anzsvs.org).

We are excited to welcome Dr Nedal Katib (http://www.specialistvascular.com.au/dr-nedal-Katib/). Dr Katib completed his Vascular Surgery Training through the Royal Australasian College of Surgeons, which took him to South Australia, New Zealand and New South Wales. He also completed a further fellowship in Belgium in advanced Endovascular and Minimally Invasive Surgery.

Originally born in Melbourne, his career path has taken him all over the world including Dubai UAE and graduating from the Royal College of Surgeons in Dublin Ireland before returning to Australia to continue his surgical career. During his training he completed his masters in surgical anatomy at Sydney University and his United States Medical Licensing Exams (ECFMG licence). Dr Katib is also the chair of communications for the ANZSVS.

Episode 16: Radiation Safety

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 08 Sep 2021 07:00:00 +1000

Absorbed dose, effective dose, equivalent dose, air kerma and Marie Curie. In this episode, we dive into radiation safety.

Episode 15: Hyperhidrosis and thorascopic sympathectomy feat. Dr Edward Travers

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 18 Aug 2021 07:00:00 +1000

In this special episode, we are joined by Adelaide vascular surgeon Dr Edwards Travers to discuss the sometimes daunting and confusing area of hyperhidrosis management.

Episode 14: The Paclitaxel Controversy feat. Professor Ramon Varcoe

Dr Sam Farah and Dr Yogeesan Sivakumaran — Thu, 12 Aug 2021 14:00:00 +1000

In this very special episode, we are joined by Professor Ramon Varcoe to discuss his updated meta-analysis on the mortality rates after paclitaxel coated device use in patients with occlusive femoropopliteal disease.

Found in the Journal of Endovascular Therapy: https://pubmed.ncbi.nlm.nih.gov/34106028/

Episode 13: Reflections on the Vascular Surgery Fellowship Examination 2021 feat. Dr Kalpa Perera

Dr Sam Farah and Dr Yogeesan Sivakumaran — Thu, 22 Jul 2021 07:00:00 +1000

In this weeks episode we are joined by Dr Kalpa Perera, a final year vascular surgery trainee who recently successfully completed the Royal Australasian College of Surgeon Fellowship Examination in Vascular Surgery in Melbourne. He reflects on his time as a vascular surgery trainee, and shares insights and advice about the strategies he used to succeed in the exam.

Episode 12: Acute limb ischaemia

Dr Sam Farah and Dr Yogeesan Sivakumaran — Sat, 10 Jul 2021 08:00:00 +1000

In this episode of The Retrograde Approach, Yogi and Sam delve into the world of acute limb ischaemia.

Episode 11: Meet the Expert feat. Mr Iman Bayat. Intravascular ultrasound, May Thurner Syndrome and Iliofemoral DVT

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 14 Jun 2021 09:00:00 +1000

In this weeks episode of The Retrograde Approach, we are joined by Mr Iman Bayat. Mr Bayat is the Head of vascular surgery at Northern Health and Head of complex venous disorders at Northern Health. In this episode he shares with us a wealth of knowledge when it comes to managing all things iliofemoral. Buckle up, this is a good one!

Episode 10: Management of tibial vessel disease

Dr Sam Farah and Dr Yogeesan Sivakumaran — Fri, 21 May 2021 08:00:00 +1000

In this episode we discuss our decision making and thought processes when it comes to managing tibial vessel disease, including open reconstruction and endovascular procedures.

Episode 9: Surgical Selection Interviews

Dr Sam Farah and Dr Yogeesan Sivakumaran — Wed, 12 May 2021 09:00:00 +1000

In this episode of The Retrograde Approach, we are joined by Dr Tom Lovelock, a first year vascular surgery trainee to talk about his strategy and approach for success in the selection process for vascular surgery training, and unpack his strategy to conquer the selection interview.

Episode 8: Ruptured abdominal aortic aneurysms

Dr Sam Farah and Dr Yogeesan Sivakumaran — Fri, 30 Apr 2021 16:00:00 +1000

In this episode Yogi and Sam discuss their management, work up and assessment of ruptured abdominal aortic aneurysms.

Link to Journal of Vascular Surgery article

https://www.jvascsurg.org/article/S0741-5214(20)32132-7/fulltext

Episode 7: Infrainguinal bypass

Dr Sam Farah and Dr Yogeesan Sivakumaran — Fri, 23 Apr 2021 20:00:00 +1000

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

Episode 6: Popliteal Artery Aneurysms

Dr Sam Farah and Dr Yogeesan Sivakumaran — Thu, 08 Apr 2021 09:00:00 +1000

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.

Episode 5: Endovascular aneurysm repair and planning

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 29 Mar 2021 20:00:00 +1000

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

Episode 4: Blunt Thoracic Aortic Injury

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 22 Mar 2021 18:00:00 +1000

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

Episode 3: The Fellowship Exam in Vascular Surgery Part 3

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 08 Mar 2021 07:00:00 +1000

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.

Episode 2: The Fellowship Exam in Vascular Surgery Part 2

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 01 Mar 2021 05:00:00 +1000

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.

Episode 1: The Fellowship Exam in Vascular Surgery Part 1

Dr Sam Farah and Dr Yogeesan Sivakumaran — Mon, 22 Feb 2021 05:00:00 +1000

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.