1. Pallor
2. Poikilotermia
3. Pulselessness
4. Paralysis
5. Paresthesia
6. Pain

1. Type A : Ascending Aorta and Aortic Arch
2. Type B : Distal to the Subclavian Artery

23 years old female in Shock with abdominal distention, increased WBC and Lactate Level.

CT A/P: Pneumatosis Intestinalis and Small Bowel Thickenining

1. 6 mm in diameter
2. 0.6 cm from skin surface
3. 6 cm in lenght
4. >600 ml/min of flow by US

1. Food Fear
2. Abdominal pain upon meals
3. Weight Loss
4. History of CAD, CVA and /or PAD

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) randomized 659 patients with symptomatic carotid stenosis > 70% into a medical treatment (aspirin, blood pressure control) arm and a surgical (carotid endarterectomy) arm. The risk for ipsilateral stroke at 2 years with medical management was 26% and the risk for any stroke or death was 32%. For carotid endarterectomy, the risk for ipsilateral stroke was 9% at 2 years.

The Asymptomatic Carotid Atherosclerosis (ACAS) Study randomized 1662 patients with a > 60% asymptomatic carotid stenosis into a surgical (carotid endarterectomy) arm and a medical management arm (mainly aspirin therapy). After a mean of 2.7 years of follow-up, the 5-year Kaplan-Meier projected risk for any stroke or death with medical management alone was 11% compared to a 5.1% risk in those who underwent carotid endarterectomy. This large study concluded that all good surgical risk patients with this type of carotid lesion be considered for carotid endarterectomy. It has been suggested that the current widespread use of statins, ACE inhibitors and advanced antiplatelet drugs (e.g. clopidogrel) may have likely lowered that risk of stroke in asymptomatic patients with carotid stenosis. At the present time, carotid endarterectomy remains both indicated and the gold standard for stroke reduction in good surgical risk patients.

CREST is a multicenter, prospective, randomized, controlled trial with primary endpoints of composite occurrence of stroke, MI or death from any cause during a 30-day periprocedural period, or postprocedural stroke within four years of randomization. Inclusion criteria included asymptomatic patients with at least 60% stenosis and symptomatic patients with at least 50% stenosis by angiography. More than 2500 patients were randomized. There was no difference in the composite endpoint of stroke, death, MI or long-term ipsilateral stroke at 4 years (7.2% CAS vs. 6.8% CEA, p=.51). There were more strokes with CAS (4.1% vs. 2.3%, p=.01) and more MIs with CEA (1.1% vs. 2.3%, p=.03). There was no difference in mortality. Patients who had a stroke were more impaired than patients with MI regardless of treatment group. At one year, cranial nerve injuries had no impact on quality of life. The impact of stroke as measured by a variety of indices of quality of life was more significant than either MI or cranial nerve injury. The periprocedural death rate was equivalent for CAS 

Goldman Criteria 

Mi

S3 gallop

Arrhythmia 

5 PVC

Aortic stenosis

Intrathoracic or abdominal aorta

Emergent operation

CRI Crea > 3

Class IV Goldman had preoperative mortality of 56%

Another index is the revised Goldman, known as the Lee index.

High-risk procedure

Ischemic heart disease 

CHF

Cav

Idem

Crea more than 2

Class IV had an 11% preoperative mortality 

ACC guidelines

High risk 

mi, unstable angina, recompensed CHF, high-grade av block, symptomatic be trivial arrhythmia, supraventricular arrhythmia, valvular disease,

Portal Hypertension: endovascular therapies

Pathophysiology of portal hypertension

Extrahepatic and intrahepatic causes of portal hypertension

3 types of portal hypertension  : pre, intra and post hepatic 

Portal hypertension 

Portosystemic gradient :  > 6mmhg

Portal pressure > 10 mmhg

increased intra hepatic vascular resistance may be structural and due to vascular tone.

Cirrhosis is an intra hepatic fibrotic process

Most Common location for esophageal varices is the ge junction .

Bleeding :20-60% mortality rate 

Varices may occur in other location 

- stomach : occur later and higher risk of bleeding and higher risk of rebleeding 

- rectal 

- peristomal 

-caput madusae

- Retro peritoneal 

Isolated gastric varices : splenic vein thrombosis

Ascites is also present in portal hypertension .

The normal flow in the thoracic duct is 4l/ day.

In Ascites the thoracic duct flow is 5 times as normal .

Hepatic encephalopathy is seen in portal hypertension due to hepatofugal blood flow.

Stage 1 : tremor ; stage 2 asterixis ; stage 3 clonus ; stage 3 postural changes 

Decompensation of liver disease 

Jaundice

Bleeding gums and brushing 

Ascites 

Encephalopathy

Sob

Spider angiomata 

Caput medusae

Child classification and Meld score( crea, total bil, inr) predict the severity and the 30 day mortality .

PV :75 % of blood flow 

Ha : 25 % 

Hepatic vein anatomy

RHV : 9 o clock

MHV : 6-9 o'clock

LHV :3-6  o'clock

Variations are present in 30 % of patients 

Budd Chiari 

Hepatic veno-occlusive disease 

Intra hepatic venules , hepatic veins and IVC. 

Spider net angiographic appearance .

Portal vein anatomy

Extra hepatic bifurcation in 50% of cases . This is a very important variation.

Several variants of portal venous anatomy.

Right posterior, Right anterior and left portal vein.

TIPS

Covered part and uncovered portion of the stent.

The open part is in the portal vein.

Acute GI bleed , Ascites and BuddChiari are the  major indications for TIPS.

Contraindications. :

Right ChF, pulmonary hypertension, policystic liver disease, acute liver failure , biliary obstruction and severe liver encephalopathy .

PreTIPS

Poor 30 day mortality 

Child C

MELD > 20

Crea > 1.9

Hepatorenal syndrome

Crossmatch for blood, platelet, correct coagulopathy , antibiotic, paracentesis ( improves vascular anatomy).

TIPs 

MR and CT localization of the portal vein 

Wedged /Balloon portal CO2 veno graphy

Shunts

RHV RPV

MHV RPV

MHV LPV

lHV LPV

Once access is gained, PV, RA pressures are acquired .A portal veno gram is then obtained .

Covered stent shave changed the patency rate of TIPS

Patency 80% at 1 year

Assisted Patency rate 98% at 1 year

In the era of non covered stent graft the patency rate at 1year was 50 %.

Survival 

1 year 70%

2 years 60 %

5 years 50%

Ascites/ hydro thorax control 66% 

Hemorrhage Control: 90% 

Rebleeding : 3-5 % with33% mortality

The higher mortality rate belongs more to the bare mates stent era.

Patients are followed with Doppler at 3 months and 6 months .

If any problems with Doppler flows : portal veno graphy 

Thrombosis, stent migration , late dysfunction and more rarely portal vein and hepatic vein injuries .

The decompression is immediate but for the Ascites to subside it will take a couple of weeks .