Opting for research on  adult stem cells  rather than  embryonic stem cells  resulted amidst the  stem cell controversy  that involve diverse ethical concerns and  religious groups , most prominently the  Catholic Church .  Embryonic stem cells  till this day are frowned upon many for the implication of the destruction of  human embryos , yet the progress of adult stem cells has produced more promising results.


After the introduction of the subject of stem cells into the mainstream, it was of utmost importance to keep the public aware of the difference of  embryonic Stem Cells  and adult stem cells. To help clarify the matter, in 2006 the  Pope  of the Catholic Church openly stated the encouragement on research on adult stem cells. [ 10 ] [ 11 ]


In 2008, after years of research the University of Pittsburgh and the UCLA come together sharing their progress in order to the develop a viable stem cell treatment.


Dr. Kotaro Yoshimura was one of the first to implement an alternative to  breast augmentation  by safely grafting fat  stem cells  in 2006. [ 12 ] [ 13 ] [ 14 ] [ 15 ]  In 2009 at the  University of Tokyo  he was able to determine the adequate pressure for grafting ADSC more effectively, paving the road to diverse applications for the future. After this breakthrough the engraftment rate was improved even further thanks to the development of a nanoscale shielding using  biomaterials  approved by the U.S.  Food and Drug Administration  (FDA). With this, Dr. Fushih Pan was able to successfully develop a safe and reliable medical procedure now known as the MIRA Procedure.


The concept of the MIRA procedure can be considered more off as a  minimally invasive   tissue graft  which function restoring capabilities work under the principles of adult stem cells. The treatments potential use lies in improving patients with chronic diseases such as heart and  liver failure  as well as those with neurodegenerative diseases like  Alzheimer's disease  and  multiple sclerosis . In 2010, the MIRA procedure spawned highly efficient alternatives to some operations in the field of cosmetics. The MIRA Lift is now an alternative for a  face lift  that rejuvenates the face's skin cells in order to produce more  collagen  for better and more natural results. Currently an alternative for  breast augmentation  surgery is also being implemented. All this is done in a  minimally invasive  way that involves almost no  downtime  to the patient.


The MIRA procedure consists of the following steps:


The MIRA Procedure has numerous applications for different fields and many more are still in development:


Clinical applications


Cosmetic  applications


Medical field:


Cosmetic field:


Patients who are not physically adequate to undergo a  liposuction  may not be subject for a MIRA procedure.


A drawback for the breast augmentation surgery is that it only provides half the extra volume when compared to current  implants .


Currently the MIRA Procedure is most well known as an alternative to  cosmetic surgery  but has proved to be successful in restoring health to patients with chronic heart disease and cirrhotic liver. Soon enough further research will be employed to develop an adequate treatment for certain types of  cancer  as well as neuro-degenerative diseases with more efficacy.


The MIRA Procedure has proven to be a significant alternative to Embryonic Stem Cell treatments which still are under development. The procedure also has some advantages over Embryonic Stem Cell treatments due to its simplicity and therefore its financial cost.


Open aortic surgery  ( OAS ), also known as  open aortic repair  ( OAR ), describes a technique whereby an  abdominal ,  thoracic  or  retroperitoneal  surgical incision is used to visualize and control the  aorta  for purposes of treatment, usually by the replacement of the affected segment with a prosthetic  graft . OAS is used to treat  aneurysms  of the  abdominal  and  thoracic  aorta,  aortic dissection ,  acute aortic syndrome , and  aortic ruptures .  Aortobifemoral bypass  is also used to treat  atherosclerotic  disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by  endovascular aneurysm repair  (EVAR) as the most common technique for repairing  abdominal aortic aneurysms  in the United States. [ 1 ]


Depending on the extent of the aorta repaired, an open aortic operation may be called an  Infrarenal aortic repair , a  Thoracic aortic repair , or a  Thoracoabdominal aortic repair . A thoracoabdominal aortic repair is a more extensive operation than either an isolated infrarenal or thoracic aortic repair.


OAS is distinct from  aortic valve repair  and  aortic valve replacement , as OAS describes surgery of the aorta, rather than of the heart valves. When the  aortic valve  is diseased in addition to the  ascending aorta , the  Bentall procedure  is used to treat the entire  aortic root . An axillary-bifemoral bypass is another type of  vascular bypass  used to treat aortic pathology, however it is not true open aortic surgery as it reconstructs the flow of blood to the legs from the arm, rather than in the native location of the aorta.


Open aortic surgery (OAS) is used to treat patients with aortic aneurysms greater than 5.5 cm in diameter, to treat  aortic rupture  of an  aneurysm  any size, to treat  aortic dissections , and to treat  acute aortic syndrome . It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the  valve-sparing aortic root replacement .


Prior to the advent of  endovascular aneurysm repair  (EVAR), OAS was the only surgical treatment available for aortic aneurysms. The shift away from open aortic surgery towards endovascular surgery since 2003 has been driven by worse  perioperative mortality  associated with OAS, particularly in patients in relatively frail health. [ 2 ]  Unlike endovascular repair, there are no strict anatomic contra-indications to open repair; Rather, open repair is viewed as the fall back option for patients with unfavorable anatomy for endovascular repair. [ 3 ]   The main drawback of open repair is the larger physiologic demand of the operation, which is associated with increased rates of short term mortality in most studies. [ 4 ]


OAR is still preferred to EVAR at some institutions and by some patients as it may be more durable than EVAR, [ 5 ]  and does not require post-operative surveillance  CT scans .


Patients younger than 50 years with descending and thoracoabdominal aortic aneurysm have low surgical risks, and open repairs can be performed with excellent short-term and durable long-term results. Open surgical repairs should be considered initially in younger patients requiring descending and thoracoabdominal aortic aneurysm repairs. Heritable thoracic aortic disease (HTAD) warrants closer postoperative surveillance. [ 6 ]


OAS is sometimes required for patients who have previously undergone EVAR but need further treatment, such as for degeneration of the EVAR seal zones leading to continued aneurysm growth. OAS is also sometimes required in cases of EVAR graft infection where the stent graft is removed to treat the infection. [ 7 ]


Open surgery typically involves exposure of the dilated portion of the aorta and insertion of a synthetic ( Dacron  or  Gore-Tex ) graft (tube). Once the graft is sewn into the proximal (toward the patient's head - and more specifically, towards their aortic valve) and distal (toward the patient's foot) portions of the aorta, the aneurysmal sac is closed around the graft.


The aorta and its branching arteries are cross-clamped during open surgery. This can lead to inadequate blood supply to the spinal cord, resulting in  paraplegia , when repairing thoracic aneurysms. A 2004 systematic review and meta analysis found that cerebrospinal fluid drainage (CFSD), when performed in experienced centers, reduces the risk of ischemic spinal cord injury by increasing the perfusion pressure to the spinal cord. [ 8 ]  A 2012 Cochrane systematic review noted that further research regarding the effectiveness of CFSD for preventing a spinal cord injury is required. [ 9 ]


The infrarenal aorta can be approached via a transabdominal midline or paramedian incision, or via a retroperitoneal approach.


The paravisceral and thoracic aorta are approached via a left-sided posteriolateral thoracotomy incision in approximately the 9th intercostal space. [ 10 ]  For a thoracoabdominal aortic aneurysm, this approach can be extended to a median or paramedian abdominal incision to allow access to the iliac arteries.


At medical centers with a high volume of open aortic surgery, the fastest option for open aortic surgery was sequential aortic clamping or "clamp-and-sew", whereby the aorta was clamped  proximally  and  distally  to the diseased segment, and a graft sewn into the intervening segment. [ 11 ]  This technique leaves the branches of the aorta un-perfused during the time it takes to sew in the graft, potentially increasing the risk of  ischemia  to the organs which derive their arterial supply from the clamped segment. Critics of this technique advocate intra-operative aortic perfusion. [ 12 ]  In infrarenal aneurysms, the relative tolerance of the lower extremities to ischemia allows surgeons to clamp distally with low risk of ill effect.


A number of techniques exist for maintaining perfusion to the viscera and spinal cord during open thoracoabdominal aortic aneurysm repair, including left heart bypass, balloon perfusion catheter placement in the visceral arteries, selective spinal drainage and cold crystalloid renal perfusion. [ 13 ]  There is limited evidence supporting these techniques. [ 14 ]


In OAS for infra-renal aneurysms, the abdominal aorta is anastomosed preferentially to the main limb of a tube or bifurcated graft in an end-to-end fashion to minimize turbulent flow at the proximal anastomosis. If normal aorta exists superior to the iliac bifurcation, a tube graft can be sewn distally to that normal aorta. If the distal aorta is diseased, a bifurcated graft can be used in an aorto-billiac or aorto-bifemoral configuration. If visceral vessels are involved in the diseased aortic segment, a branched graft can be used with branches sewn directly to visceral vessels, or the visceral vessels can be separately revascularized. [ citation needed ]


Because of collateral blood flow from the  superior mesenteric artery  (SMA) via the  marginal artery , the  inferior mesenteric artery  usually does not have to be reimplanted into the aortic graft when performing an open abdominal aortic aneurysm repair.


OAS is widely recognized as having higher rates of perioperative morbidity and mortality than endovascular procedures for comparable segments of the aorta. For example, in infrarenal aneurysms, perioperative mortality with endovascular surgery is approximately 0.5%, against 3% with open repair. [ 15 ]


Besides the risk of death, other risks and complications with OAS depend on the segment of aorta involved, and may include renal failure, spinal cord ischemia leading to paralysis, buttock claudication, ischemic colitis, embolization leading to acute limb ischemia, infection, and bleeding. [ 16 ]  Development of spinal cord injury is associated with increased
perioperative mortality after the complex aortic repair. [ 17 ]


Aortic graft infections occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are  Staphylococcus aureus , and coagulase-negative staphylococci, followed by  Enterobacterales  and uncommon bacteria. In case of gut involvement also fungi may play a role. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive antibiotic therapy. In selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. [ 18 ]


Recovery time after OAS is substantial. Immediately following surgery, patients can expect to spend 1–3 days in the intensive care unit, followed by 4–10 days on the hospital ward. After discharge, patients will take 3–6 months to fully recover their energy and return to their pre-operative daily activities. [ citation needed ]  However, enhanced recovery after surgery (ERAS) protocols can improve recovery following surgery. [ 19 ]


Open repair for thoracoabdominal aneurysms requires a very large incision that cuts through muscles and sometimes bones making recovery very difficult and painful for the patient. Intraoperative intercostal nerve cryoanalgesia has been used during procedure to help reduce pain after TAAA. [ 20 ]


The history of aortic surgery dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century CE.  Many advancements of OAS have been developed in the past century.


In 1955, cardiovascular surgeons, Drs.  Michael DeBakey  and  Denton Cooley  performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the Dacron graft, resulting in a revolution for surgeons in the surgical repair of aortic aneurysms. [ 21 ]  DeBakey was first to perform  cardiopulmonary bypass  to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery.


By the mid-1960s, at  Baylor College of Medicine , DeBakey’s group began performing surgery on thoracoabdominal aortic aneurysms (TAAA), which presented formidable surgical challenges, often fraught with serious complications, such as paraplegia, paraparesis and renal failure. DeBakey protégé and vascular Surgeon, E. Stanley Crawford, in particular, began dedicating most of his time to TAAAs.  In 1986, he classified TAAA open surgery cases into four types: [ 22 ]  Extent I, extending from the left subclavian artery to just below the renal artery; Extent II, from the left subclavian to below the renal artery; Extent III, from the sixth intercostal space to below the renal artery; and Extent IV, from the twelfth intercostal space to the iliac bifurcation (i.e. total abdominal).


In 1992, another classification, Extent V, characterized by  Hazim J. Safi , MD, identified aneurysmal disease extending from the sixth intercostal space to above the renal arteries.  Safi's group used experimental animal models for a prospective study on the use distal aortic perfusion, cerebrospinal fluid drainage, moderate hypothermia and sequential clamping to decrease in the incidence of neurological deficit. In 1994, they presented their experiences, showing that the incidence for Extent I and II dropped from 25% to 5%. [ 23 ]  This marked a new era for protecting the spinal cord, brain, kidneys, heart and lungs during OAS on TAAA.


Postoperative paraplegia and paraparesis have been the scourge of thoracoabdominal aortic repair since the inception of the procedure. [ 24 ]  However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication [ 25 ]


A  peripheral vascular examination  is a medical examination to discover  signs  of  pathology  in the  peripheral vascular system . It is performed as part of a  physical examination , or when a patient presents with leg pain suggestive of a cardiovascular pathology.


The exam includes several parts:


Position – patient should be lying in the  supine position  and the bed or examination table should be flat. The patient's hands should remain at their sides with their head resting on a pillow.


Lighting – adjusted so that it is ideal.


Draping – the legs should be exposed, the groin and thigh covered. Drapes are usually placed between the legs.


On inspection the clinician looks for signs of:


The  Perthes test  is a clinical test for assessing the patency of the deep femoral vein prior to varicose vein surgery. [ 1 ]  It is named after German surgeon  Georg Perthes .


The limb is elevated and an elastic bandage is applied firmly from the toes to the upper 1/3 of the thigh to obliterate the superficial veins only. With the bandage applied the patient is asked to walk for 5 minutes. If deep system is competent, the blood will go through and back to the heart.
If the deep system is Blocked(has a thrombus), the patient will feel pain in the leg.


This test is sometimes referred to as the Delbet-Mocquot test, named after French physicians  Pierre Delbet  and  Pierre Mocquot .


The test is done by applying a tourniquet at the level of the sapheno-femoral junction to occlude the superficial pathway, and then the patient is asked to move in situ. If the deep veins are occluded, the dilated veins increase in prominence.This is essential before performing a surgery for varicose veins i.e. The Trendelenberg procedure so as to ascertain the patency of deep venous system before removing or ligating the superficial system


This is a more objective test as it does not depend on patient's pain threshold.


This  medical  diagnostic article is a  stub . You can help Wikipedia by  expanding it .


Phlebotomy  is the process of making a puncture in a  vein , usually in the arm, with a  cannula  for the purpose of  drawing blood . [ 1 ]  The procedure itself is known as a  venipuncture , which is also used for  intravenous therapy . A person who performs a phlebotomy is called a  phlebotomist , although most doctors, nurses, and other technicians can also carry out a phlebotomy. [ 2 ]  In contrast,  phlebectomy  is the removal of a vein.


Phlebotomies that are carried out in the treatment of some  blood disorders  are known as  therapeutic phlebotomies . [ 3 ]  The average volume of whole blood drawn in a therapeutic phlebotomy to an adult is 1 unit (450–500 ml) weekly to once every several months, as needed. [ 4 ]


From  Ancient Greek :  φλεβοτομία  ( phlebotomia  –  phleb  'blood vessel, vein' +  tomia  'cutting'), via  Old French :  flebothomie  (modern French  phlébotomie ). [ citation needed ]


Phlebotomies are carried out by phlebotomists – people trained to draw blood mostly from veins for clinical or medical testing, transfusions, donations, or research. Blood is collected primarily by performing  venipunctures , or by using  capillary blood sampling  with [ 5 ]   fingersticks  or a  heel stick  in infants for the collection of minute quantities of blood. [ 6 ]  The duties of a phlebotomist may include interpreting the tests requested, drawing blood into the correct tubes with the proper additives, accurately explaining the procedure to the person and preparing them accordingly, practicing the required forms of  asepsis , practicing standard and  universal precautions , restoring  hemostasis  of the puncture site, giving instructions on post-puncture care, affixing tubes with electronically printed labels, and delivering specimens to a laboratory. [ 7 ]  Some countries, states, or districts require that phlebotomists be licensed or registered. [ citation needed ]


A  therapeutic phlebotomy  may be carried out in the treatment of some blood disorders (example:  Hemochromatosis ,  polycythemia vera ,  porphyria cutanea tarda ), and  chronic hives  (in research). [ 8 ] [ 9 ]


In  Australia , there are a number of courses in phlebotomy offered by educational institutions, but training is typically provided on the job. The minimum primary qualification for phlebotomists in Australia is a Certificate III in Pathology Collection (HLT37215) from an approved educational institution. [ 10 ]


In the  UK  there is no requirement for holding a formal qualification or certification prior to becoming a phlebotomist as training is usually provided on the job. The  NHS  offers training with formal certification upon completion. [ 11 ]


Special state certification in the  United States  is required only in four states:  California ,  Washington ,  Nevada , and  Louisiana . A phlebotomist can become nationally certified through many different organizations. However, California currently only accepts national certificates from six agencies. These include the  American Certification Agency  (ACA),  American Medical Technologists  (AMT),  American Society for Clinical Pathology  (ASCP),  National Center for Competency Testing / Multi-skilled Medical Certification Institute  (NCCT/MMCI),  National Credentialing Agency  (NCA), and  National Healthcareer Association  (NHA). [ 12 ]  These and other agencies such as the American Society of Phlebotomy Technicians also certify phlebotomists outside the state of California. To qualify to sit for an examination, candidates must complete a full phlebotomy course and provide documentation of clinical or  laboratory  experience.


In  South Africa  learnerships to qualify as a Phlebotomy Technician are offered by many public and private educational institutions as well as by private academies owned up by pathology laboratories (such as Ampath Laboratories, Lancet, PathCare) and healthcare service providers (such as  Netcare ,  South African National Blood Service ). Some of the larger retail pharmacy chains offering in-store clinical services (such as Clicks,  Dis-Chem ) also provide training for aspirant phlebotomists. Certification can be obtained from a number of examination and testing institutions. To work as a phlebotomist in South Africa, registration with the  Health Professions Council of South Africa  (HPCSA) is required.


("light blue")


(weak calcium chelator/ anticoagulant )


Plasma separator gel


("navy")


Fluoride Oxalate


Grey, Green, Yellow, Purple


1. Grey (nil) tube
2. Green (TB1 antigen) tube
3. Yellow (TB2 antigen) tube
4. Purple (mitogen) tube


A phlebotomy draw station is a place where blood is drawn from patients for laboratory testing, transfusions, donations, or research purposes. The blood is typically drawn via  venipuncture  or a  finger stick  by a healthcare professional such as a  phlebotomist ,  nurse , or  medical assistant . [ 21 ]
The draw station typically includes a padded chair or a bed for patients prone to fainting during blood draws.
Draw stations can be found in various settings, such as hospitals, clinics, blood donation centers, and independent laboratories or as part of  patient service centers  (PSC).


Early phlebotomists used techniques such as  leeches  and incision to extract blood from the body. Bloodletting was used as a therapeutic as well as a prophylactic process, thought to remove toxins from the body and to balance the  humors . While physicians did perform bloodletting, it was a specialty of  barber surgeons , the primary provider of health care to most people in the medieval and early modern eras.


Polidocanol  is a  local anaesthetic  and  antipruritic  component of  ointments  and bath additives. It relieves itching caused by   eczema  and dry skin. [ 2 ]  It has also been used to treat  varicose veins , [ 3 ]   hemangiomas , and  vascular malformations . [ 4 ]  It is formed by the  ethoxylation  of  dodecanol .


Polidocanol is also used as a  sclerosant , an  irritant  injected to treat  varicose veins , under the trade names  Asclera ,  Aethoxysklerol [ 5 ]  and  Varithena . [ 6 ]  Polidocanol causes  fibrosis  inside varicose veins, occluding the  lumen  of the vessel, and reducing the appearance of the varicosity.


The FDA has approved polidocanol injections for the treatment of small varicose (less than 1 mm in diameter) and reticular veins (1 to 3 mm in diameter). Polidocanol works by damaging the cell lining of  blood vessels , causing them to close and eventually be replaced by other types of tissue. [ 7 ] [ 8 ]  Polidocanol in the form of Varithena injected in the greater saphenous vein can cause the eruption of varicose and spider veins throughout the lower leg. This procedure should be done with caution and with the knowledge that the appearance of the leg may be forever compromised.


This  drug  article relating to the  cardiovascular system  is a  stub . You can help Wikipedia by  expanding it .


This  dermatologic   drug  article is a  stub . You can help Wikipedia by  expanding it .


The  popliteal artery entrapment syndrome  (PAES) is an uncommon  pathology  that occurs when the popliteal artery is compressed by the surrounding popliteal fossa myofascial structures. [ 1 ]  This results in  claudication  and chronic leg  ischemia . This condition mainly occurs more in young athletes than in the elderlies. [ 2 ]  Elderlies, who present with similar symptoms, are more likely to be diagnosed with  peripheral artery disease  with associated  atherosclerosis . [ 2 ]  Patients with PAES mainly present with intermittent feet and calf pain associated with exercises and relieved with rest. [ 3 ]  PAES can be diagnosed with a combination of medical history, physical examination, and advanced imaging modalities such as  duplex ultrasound ,  computer tomography , or  magnetic resonance angiography . Management can range from non-intervention to open surgical decompression with a generally good prognosis. [ 4 ]  Complications of untreated PAES can include stenotic artery degeneration, complete popliteal artery occlusion, distal arterial thromboembolism, or even formation of an  aneurysm .


In 1879, the syndrome was first described in a 64 years old male by Anderson Stuart, a  medical student . [ 1 ]  In 1959, Hamming and Vink first described the management of the PAES in a 12-year-old patient. The patient was treated with  myotomy  of the medial head of the  gastrocnemius muscle  and  concomitant   endarterectomy  of the popliteal artery. They later reported four more cases and claimed that the incidence of this pathology in patients younger than 30 years old with claudication was 40%. Servello was the first to draw attention to diminished distal pulses observed with forced plantar- or dorsiflexion in patients with this syndrome. [ 5 ]  In 1981, Bouhoutsos and Daskalakis reported 45 cases of this syndrome in a population of 20,000 Greek soldiers. [ 6 ]  Over the last few decades, the increasing frequency with which popliteal artery entrapment is reported, strongly suggests greater awareness of the syndrome. [ 7 ]


In the general population, popliteal artery entrapment syndrome (PAES) has an estimated  prevalence  of 0.16%. [ 8 ]  It is most commonly found in young, physically active males. [ 2 ]  In fact, sixty percent of all cases of this syndrome occur in athletically active males under the age of 30. [ 9 ]  The predilection of this syndrome presents in a male to female ratio of 15:1. [ 8 ]  This discrepancy in prevalence may be overestimated due the findings that males are generally found to be more physically active than females or because a large portion of the data is from military hospitals that treat mostly male populations. [ 9 ]  People, who participate in running, soccer, football, basketball, or rugby, are at increased risk. [ 10 ]


Newborns and young children are also at increased PAES risk due to congenital causes. During  embryonic development , the medial head of  gastrocnemius  migrates medially and superiorly. This migration can cause structural abnormalities, such as irregular positioning of the  popliteal artery , and can account for the rare instances of entrapment caused by the  popliteus muscle . [ 9 ]  Less than 3% of all people are born with this anatomical defect that progresses into PAES, and of those who are born with the anatomical defect, the majority never develop  symptoms . [ 10 ]  Bilateral presentation of PAES is found in approximately 30% of cases. [ 11 ]


PAES can be classified as either congenital or functional. [ 3 ]  Analysis of human embryological development has shown that the popliteal artery and the medial head of the gastrocnemius muscle arise at approximately the same time. Because of that, abnormal development of muscle's position in relation to the nearby vessels can result in potential vascular compromise. [ 3 ]  The varying types of PAES can be classified based on aberrant migration and resultant attachments of the medial head of the gastrocnemius muscle. Type VI PAES (functional PAES) describes a subtype that is due to repeated  microtrauma  resulting in the destruction of the internal elastic lamina and damage to the smooth muscles resulting in  fibrosis  and scar formation.


Additionally, a more practical classification system was introduced by Heidelberg et al. [ 12 ]  This system classifies PAES into three main types:


Patients with PAES are typically healthy young males without previous history of cardiovascular risk factors such as smoking,  hypertension ,  hypercholesterolemia , or  diabetes . [ 13 ]  Typically, patients present with  intermittent claudication  that is worsened with exercise and relieved with rest. [ 3 ]  Associated symptoms include numbness, discoloration, pallor, and coolness in the affected lower extremity. [ 13 ]  Physical examination of suspected PAES may show  hypertrophy  of the calf muscles, as well as diminished, unequal, or absent pulses in the lower extremity upon plantar- or dorsiflexion. [ 14 ]


PAES should be suspected in young healthy male patients with clinical symptoms consistent with compression of the vascular structures and without significant cardiovascular risk factors such as smoking. [ 13 ]  Multiple imaging modalities are used to confirm the diagnosis of PAES. [ 23 ]  Based on a systemic review by Sinha et al,  digital subtraction angiography  (DSA) is the most common imaging used for PAES diagnosis, followed by  ankle–brachial index  (18 percent),  computed tomography angiography  (CTA) (12 percent),  magnetic resonance angiography  (MRA) (12 percent),  duplex ultrasonography  (DU) (10 percent), exercise ankle-brachial index (4 percent), and other modalities (4 percent). [ 23 ]  According to a recent study by Willimas et al, a combination of DU and MRA is far superior in diagnosing PAES. [ 24 ]


Provocative maneuvers can be used to improve visualization of PAES on the imagines. [ 25 ]  The patient is initially positioned supine with the legs straight, and then instructed to forcefully plantar-flex. A plantarflexion force of 0 to 70 percent maximum has been shown to maximize the sensitivity and specificity for PAES diagnosis. [ 25 ]  The DU can be a quick, inexpensive, and noninvasive initial screening for PAES. Flow velocities in the popliteal artery will increase, as the popliteal artery is compressed, which is reflected on the DU. If DU is negative but there is still strong suspicion for PAES, MRA or CTA with provocative maneuvers are needed as follow-up imaging. MRA would demonstrate a focal occlusion or narrowing of the mid-popliteal artery, post-stenotic dilatation, or aneurysm of the distal popliteal artery. If MRA or CTA is [ 13 ]  non-conclusive, DSA may be used as a further option with a high sensitivity (> 97%) for PAES diagnosis. [ 23 ]


Additionally, functional PAES in which the gastrocnemius hypertrophy causes arterial compression during exercise can be best evaluated with dynamic CT. [ 23 ]  For dynamic CT, initial images are taken with the patient still. Further images are taken following a series of provocative maneuvers.


The outcome following the surgery is usually favorable. Successful resolution of PAES occurs in 77 percent of cases. [ 23 ]  Surgical complications include deep vein thrombosis, hematoma, wound infection, or seroma. [ 23 ]  After the surgery, patient is usually monitored using arterial duplex ultrasonography 1, 3, 6, and 12 months, and annually after that. [ 3 ]


Early detection and management of PAES can lead to a favorable outcome. [ 23 ]  However, prolonged compression of popliteal artery can lead to extensive arterial damage and permanent claudication or limb loss. [ 28 ]  Complications of PAES may include: [ 13 ]


Nonetheless, the course of PAES is often slow and takes time, thus, limbs loss is rarely seen, even in PAES patients. [ 13 ]


A  portacaval shunt ,  portocaval shunt , or  portal-caval shunt  is a surgical procedure where a connection (a  shunt ) is made between the  portal vein  and the  inferior vena cava .


Under normal circumstances, the portal vein drains blood from the abdomen to the liver. The blood is deoxygenated and carries nutrients and waste products from the intestines, spleen, pancreas, and gallbladder to the liver. [ 1 ]  The deoxyenated blood then exits the liver through the  hepatic vein  and empties into the  inferior vena cava , the vein that carries blood from the lower two-thirds of the body to the heart.


The portacaval shunt connects the portal vein to the inferior vena cava, allowing blood to travel directly from the portal vein to the inferior vena cava, bypassing the liver entirely. The shunt is typically used to manage complications of  portal hypertension , such as  upper gastrointestinal bleeding . However, technological advancements have shifted towards minimally invasive methods rather than surgical shunting.


Portal hypertension is commonly seen with liver  cirrhosis  and/or other liver diseases such as  Budd–Chiari syndrome ,  primary biliary cirrhosis  (PBC), and  portal vein thrombosis . [ 2 ]  The purpose of the shunt is to divert blood flow away from the liver, reducing the high pressure in the portal venous system and decreasing the risk of bleeding. [ 3 ]


A  portacaval anastomosis  is analogous in that it diverts circulation; as with shunts and  anastomoses  generally, the terms are often used to refer to either the naturally occurring forms or the surgically created forms.


Portacaval shunts were first developed and performed in the mid-20th century to control bleeding  varicose veins  in cases of portal hypertension. These efforts successfully controlled the bleeding; however, liver failure remained a concern and often worsened after shunt placement. Eventually, selective shunts were introduced, and soon liver transplantation became the definitive surgical solution to treating portal hypertension. [ 4 ]


Over time, less invasive treatments for portal hypertension were developed.  Sclerotherapy , a minimally invasive procedure that uses chemicals to shrink  varicose veins  through  endoscopy , was later enhanced with the introduction of variceal band ligation. Technological advancements also led to pharmacological therapies and interventional radiologic procedures like  transjugular intrahepatic portosystemic shunt  (TIPS), which is now the preferred treatment for managing portal hypertension. [ 5 ]  Portacaval shunting is no longer commonly used as the first line treatment for variceal bleeding due to the increased safety and effectiveness of the newer treatments.


Portacaval shunting is primarily indicated for uncontrolled upper gastrointestinal bleeding when medical therapy, endoscopic methods, or TIPS are not possible or ineffective. [ 6 ]  Additionally, surgical shunting may also be indicated for patients with a history of splenectomy, splenic vein or hepatic vein thrombosis, a splenorenal shunt, or  ascites , as minimally invasive methods would not be recommended in these cases. [ 6 ]


The purpose of the shunt is to redirect blood flow from the portal venous system into the systemic venous system, which reduces the pressure gradient in the portal venous circulation, thereby lowering the risk of bleeding  varices . [ 3 ]


Several types of shunts connect the portal circulation to the systemic venous circulation. The portacaval shunt specifically connects the portal vein to the inferior vena cava through a direct connection. There are two major types of portacaval shunts.


Both surgical procedures reduce portal venous pressure by diverting blood flow away from the portal venous circulation and into the systemic venous circulation. [ 7 ]


The success rate depends on several factors, including the patient's condition and the severity of the disease. Studies have shown that surgical shunting is highly effective in controlling upper gastrointestinal bleeding. [ 8 ]  The  Child–Pugh score  can be used to help determine the severity and prognosis of patients with severe liver disease. Additionally, factors such as the event's timing, whether an emergent or elective procedure is performed, and the technical success of the surgical procedure can affect the outcomes and prognosis.


The primary complication of the procedure is  hepatic encephalopathy  (HE), a cognitive dysfunction caused by the liver's reduced ability to filter toxins from the blood. Signs of symptoms of HE include confusion, disorientation, impaired memory, changes to mood, lethargy, and  asterixis . [ 9 ]


Patients that undergo portacaval shunting may have an increased risk of HE because blood bypasses the liver and allows unfiltered toxins to enter the bloodstream and reach the brain, causing cognitive dysfunction. [ 10 ]  Additionally, increased intestinal absorption of encephalopathogenic substances in combination with the reduced hepatic blood flow may also contribute to the high risk of developing HE. [ 10 ]  Surgical shunts have a higher risk of encephalopathy compared to less invasive measures due to the total redirect of blood flow away from the liver. [ 4 ]


There are general surgical risks, such as bleeding and infection, along with specific complications related to liver function with portacaval shunting. Compared to the less invasive approaches (endoscopy, TIPS), surgical shunts have an increased risk of morbidity and mortality, especially in patients with advanced disease. [ 3 ]  Complications include liver dysfunction due to altered blood flow, shunt thrombosis, and hepatic insufficiency.


Alternatives to surgical portacaval shunts include:


An interventional radiologist typically performs TIPS, which involves placing a stent between the portal vein and hepatic veins to lower blood pressure in the portal circulation. Compared to portacaval shunting, TIPS is less invasive, safer, and is now the preferred option for patients with advanced liver failure or those at high surgical risk. [ 11 ]


Both TIPS and portacaval shunting effectively reduce portal pressure but share the risk of hepatic encephalopathy (HE) due to bypassing the liver's detoxification process. In TIPS, HE symptoms can often be managed by adjusting the stent, whereas portacaval shunting provides a permanent solution without the ability to make such adjustments.


Additionally, portacaval shunting carries significantly higher morbidity and mortality rates, making TIPS the more favorable option in most cases. [ 3 ]


In medical and surgical  therapy ,  revascularization  is the restoration of  perfusion  to a body part or  organ  that has had  ischemia . It is typically accomplished by  surgical  means. [ 1 ]   Vascular bypass  and  angioplasty  are the two primary means of revascularization.


The term derives from the prefix  re- , in this case meaning "restoration" and  vasculature , which refers to the circulatory structures of an organ.


It is often combined with "urgent" to form urgent vascularization.


Revascularization involves a thorough analysis and  diagnosis  and treatment of the existing diseased vasculature of the affected organ, and can be aided by the use of different imaging modalities such as  magnetic resonance imaging ,  PET scan ,  CT scan , and  X-ray  fluoroscopy. [ citation needed ]


For  coronary artery disease  (ischemic heart disease),  coronary artery bypass surgery  and  percutaneous coronary intervention  (coronary balloon angioplasty) are the two primary means of revascularization. [ 2 ]  When those cannot be done,  transmyocardial revascularization  or percutaneous myocardial revascularization, done with a laser, may be an option.


Treatment for  gangrene  often requires revascularization, if possible. [ 3 ]  The surgery is also indicated to treat  ischemic wounds  (inadequate  tissue  perfusion) in some forms of  chronic wounds , such as  diabetic  ulcers. [ 4 ]


Revision Using Distal Inflow  (RUDI) is a surgical treatment for  Dialysis-associated Steal Syndrome . RUDI was first proposed by David J. Minion and colleagues in 2005. In the procedure, the  fistula  is ligated at a location slightly proximal to the anastomosis. A bypass to the venous outflow is then created from a distal arterial source. [ 1 ]


In a review of a three studies on the efficacy of the technique, RUDI was shown to provide good patency (80%-100%) and 100% symptom resolution. [ 2 ]


Sclerotherapy  (the word reflects the Greek  skleros , meaning  hard ) [ 1 ]
is a procedure used to treat blood vessel malformations ( vascular malformations ) and also malformations of the  lymphatic system .  A medication is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults, sclerotherapy is often used to treat  spider veins , smaller  varicose veins ,  hemorrhoids , [ 2 ]  and  hydroceles . [ 3 ]


Sclerotherapy is one method for the treatment of spider veins, varicose veins (which are also often treated with surgery,  radiofrequency , and  laser ablation ), and venous malformations. In  ultrasound -guided sclerotherapy,  ultrasound  is used to visualize the underlying  vein  so the physician can deliver and monitor the injection. Sclerotherapy often [ quantify ]  takes place under ultrasound guidance after venous abnormalities have been diagnosed with duplex ultrasound. Sclerotherapy under ultrasound guidance and using microfoam sclerosants has been shown [ by whom? ]  to be effective in controlling reflux from the sapheno-femoral and sapheno-popliteal junctions. [ 4 ] [ 5 ]  However, some authors [ which? ]  believe that sclerotherapy is not suitable for veins with reflux from the greater or lesser  saphenous junction , or for veins with axial reflux. [ 2 ]  This is due to the emergence of more effective technologies, including laser ablation and radiofrequency, which have demonstrated superior efficacy to sclerotherapy for treatment of these veins. [ 6 ]


Sclerotherapy has been used in the treatment of spider veins and occasionally varicose veins for over 150 years. Like varicose vein surgery, sclerotherapy techniques have evolved during that time. Modern techniques including ultrasonographic guidance and foam sclerotherapy are the latest developments in this evolution.


The first reported attempt at sclerotherapy was by D Zollikofer in Switzerland in 1682, who injected an acid into a vein to induce  thrombus  formation. [ 7 ]   Both Debout and Cassaignaic reported success in treating varicose veins by injecting perchlorate of iron in 1853. [ 8 ]  Desgranges in 1854 cured 16 cases of varicose veins by injecting iodine and tannin into the veins. [ 7 ]  This was approximately 12 years after the probable advent of  great saphenous vein   stripping  in 1844 by Madelung. [ 8 ]  However, due to high rates of side-effects with the drugs used at the time, sclerotherapy had been practically abandoned by 1894. [ 9 ]  With the improvements in surgical techniques and  anaesthetics  over that time, stripping became the treatment of choice.


Work continued on alternative sclerosants in the early 20th century. During that time carbolic acid and perchlorate of mercury were tried and whilst these showed some effect in obliterating varicose veins, side-effects also caused them to be abandoned. Prof. Sicard and other French doctors developed the use of sodium carbonate and then sodium salicylate during and after the First World War. [ 9 ]  Quinine was also used with some effect during the early 20th century. At the time of Coppleson's book in 1929, he was advocating the use of sodium salicylate or quinine as the best choices of sclerosant. [ 9 ]


Further work on improving the technique and development of safer more effective sclerosants continued through the 1940s and 1950s. Of particular importance was the development of  sodium tetradecyl sulfate  (STS) in 1946, a product still widely used to this day. George Fegan in the 1960s reported treating over 13,000 patients with sclerotherapy, significantly advancing the technique by focussing on fibrosis of the vein rather than thrombosis, concentrating on controlling significant points of reflux and emphasizing the importance of compression of the treated leg. [ 8 ]  The procedure became medically accepted in mainland Europe during that time. However, it was poorly understood or accepted in England or the United States, a situation that continues to this day amongst some sections of the medical community. [ 7 ]


The next major development in the evolution of sclerotherapy was the advent of  duplex ultrasonography  in the 1980s and its incorporation into the practise of sclerotherapy later that decade. Knight [ 10 ]  was an early advocate of this new procedure and presented it at several conferences in Europe and the United States. Thibault's article [ 11 ]  was the first on this topic to be published in a peer-reviewed journal.


The work of Cabrera [ 12 ]  and Monfreaux [ 13 ]  in utilising foam sclerotherapy along with Tessari's "3-way tap method" of foam production [ 14 ]  further revolutionised the treatment of larger varicose veins with sclerotherapy. This has now been further modified by Whiteley and Patel [ 15 ]  to use 3 non-silicone syringes for more long lasting foam.


Injecting the unwanted veins with a sclerosing solution causes the target vein to immediately shrink, and then dissolve over a period of weeks as the body naturally absorbs the treated vein. The initial "shrinkage" is caused by spasm of the muscular layer of the vein wall.  The sclerosing solution damages the vein wall, causing inflammation and gradual scarring ("sclerosis") over the following weeks. The sclerosis is caused by an increase in fibroblasts in the cell wall which causes contraction of the vein. The process requires carefully assessing the strength of the sclerosing solution so it is strong enough to cause a clinically significant effect in the target vein without causing excessive damage to surrounding tissues. [ 16 ]  Sclerotherapy is a non-invasive procedure taking only about 10 minutes to perform. The downtime is minimal, in comparison to an invasive varicose vein surgery. [ 17 ]


Sclerotherapy is the "gold standard" and is preferred over laser for eliminating large spider veins  telangiectasias . [Telangiectasia is a condition in which broken or widened small blood vessels that sit near the surface of the skin or mucous membranes create visible], and smaller varicose leg veins. [ 18 ]  Unlike a laser, the sclerosing solution additionally closes the  reticular veins  also known as  feeder veins  under the skin that are causing the spider veins to form, thereby making a recurrence of the spider veins in the treated area less likely. Multiple injections of dilute sclerosant are injected into the abnormal surface veins of the involved leg. The patient's leg is then compressed with either stockings or bandages that they wear usually for one week after treatment. [ 19 ]  Patients are also encouraged to walk regularly during that time. It is common practice for the patient to require at least two treatment sessions separated by several weeks to significantly improve the appearance of their leg veins.


Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the great and small saphenous veins. [ 20 ]  After a map of the patient's varicose veins is created using ultrasound, these veins are injected whilst real-time monitoring of the injections is undertaken, also using ultrasound. The sclerosant can be observed entering the vein, and further injections performed so that all the abnormal veins are treated. Follow-up ultrasound scans are used to confirm closure of the treated veins and any residual varicose veins can be identified and treated.


Foam sclerotherapy [ 21 ]  is a technique that involves injecting  "foamed sclerosant drugs" within a blood vessel using a pair of syringes – one with sclerosant in it and one with gas (originally air). The original Tessari method has now been modified by the Whiteley-Patel modification which uses 3 syringes, all of which are silicone-free. [ 15 ]  The  sclerosant  drugs ( sodium tetradecyl sulfate ,  bleomycin  or  polidocanol ) are mixed with air or a physiological gas ( carbon dioxide ) in a syringe or by using mechanical pumps. This increases the  surface area  of the  drug . The foam sclerosant drug is more efficacious than the liquid one in causing  sclerosis [ 22 ]  (thickening of the vessel wall and sealing off the blood flow), for it does not mix with the blood in the vessel and in fact displaces it, thus avoiding dilution of the drug and causing maximal sclerosant action. It is therefore useful for longer and larger veins. Experts in foam sclerotherapy have created “tooth paste” like thick foam for their injections, which has revolutionized the non-surgical treatment of  varicose veins [ 23 ]  and venous malformations, including   Klippel–Trénaunay syndrome . [ 24 ]


Bleomycin electrosclerotherapy consists of locally delivering the sclerosant bleomycin and applying short high voltage electrical pulses to the area to be treated, resulting in a local and temporary increased permeability of the  cell membranes , increasing the intracellular concentration of bleomycin by a factor of up to several thousand. [ 25 ]  Preclinical studies also indicated that electroporation in combination with bleomycin impaired the barrier function of the  endothelium  by interacting with the organization of the  cytoskeleton  and the integrity of the junctions. This can lead to extravasation, interstitial edema and a desired collapse of the vascular structures. [ 26 ]
The procedure has been researched as  electrochemotherapy  of skin tumors since the early 1990s [ 27 ]  and was first used in 2017 for vascular malformations. [ 28 ]  Initial reports indicated that the use of bleomycin in combination with reversible electroporation can potentially enhance the sclerotherapy effect. [ 29 ] [ 30 ]  A retrospective study of 17 patients with venous malformations who did not respond to previous invasive therapies showed an average decrease in lesion volume measured on  MRI  images of 86% with clinical improvement in all patients after an average of 3.7 months and 1.12 sessions per patient, with a reduced dose of bleomycin and a reduced number of sessions compared to standard bleomycin sclerotherapy [ 31 ]


A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution. [ 4 ]  Padbury and Benveniste [ 5 ]  found that ultrasound guided sclerotherapy was effective in controlling reflux in the small saphenous vein. Barrett et al. found that microfoam ultrasound guided sclerotherapy was "effective in treating all sizes of varicose veins with high patient satisfaction and improvement in quality of life". [ 32 ]


A  Cochrane Collaboration  review of the medical literature concluded that "the evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins." [ 33 ]  A second  Cochrane Collaboration  review comparing surgery to sclerotherapy concluded that sclerotherapy has greater benefits than surgery in the short term but surgery has greater benefits in the longer term. Sclerotherapy was better than surgery in terms of treatment success, complication rate and cost at one year, but surgery was better after five years. However, the evidence was not of very good quality and more research is needed. [ 34 ]


A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux from the sapheno-femoral or sapheno-popliteal junctions. It did not study the relative benefits of surgery and sclerotherapy in varicose veins with junctional reflux. [ 35 ]


The European Consensus Meeting on Foam Sclerotherapy in 2003 concluded that "Foam sclerotherapy allows a skilled practitioner to treat larger veins including saphenous trunks". [ 36 ]  A second European Consensus Meeting on Foam Sclerotherapy in 2006 has now been published. [ 37 ]


Complications, while rare, include  venous thromboembolism , visual disturbances,  allergic reaction , [ 38 ]   thrombophlebitis , skin necrosis, and hyperpigmentation or a red treatment area. [ 39 ]


If the sclerosant is injected properly into the vein, there is no damage to the surrounding skin, but if it is injected outside the vein, tissue necrosis and scarring can result. [ 40 ]  Skin necrosis, whilst rare, can be cosmetically "potentially devastating",  and may take months to heal. It is very rare when small amounts of dilute (<0.25%) sodium tetradecyl sulfate (STS) is used, but has been seen when higher concentrations (3%) are used. Blanching of the skin often occurs when STS is injected into arterioles (small artery branches). Telangiectatic matting, or the development of tiny red vessels, is unpredictable and usually must be treated with repeat sclerotherapy or laser. [ 41 ]


Most complications occur due to an intense inflammatory reaction to the sclerotherapy agent in the area surrounding the injected vein. In addition, there are systemic complications that are now becoming increasingly understood. These occur when the sclerosant travels through the veins to the heart, lung and brain. A recent report attributed a stroke to foam treatment, [ 42 ]  although this involved the injection of an unusually large amount of foam.
More recent reports have shown that bubbles from even a small amount of sclerosant foam injected into the veins quickly appear in the heart, lung and brain. [ 43 ]  The significance of this is not fully understood at this point and large studies show that foam sclerotherapy is safe. [ 44 ]  Sclerotherapy is fully FDA approved in the USA. [ citation needed ]


Contraindications include: bed rest, severe systemic diseases, poor patient understanding, needle phobia, short life expectancy, late stage cancer, known allergy to the sclerosing agent, and treatment with  tamoxifen . [ 45 ]


The   Society for Vascular Surgery  (SVS) an American  academic society  for  vascular surgery . Its mission includes education, research, career development and advocacy. [ 1 ]  The SVS is the national organization for more than 6,000 vascular surgeons and other medical professionals involved in the prevention and cure of  vascular disease . The association was founded in 1947. The SVS is the sponsor organization for the Journal of Vascular Surgery (JVS) and for the national Vascular Annual Meeting (VAM).


The Society for Vascular Surgery was founded in 1947 as the  Society for Cardiovascular Surgery . The society changed its name to the Society for Vascular Surgery in 1953 to reflect its focus on vascular disease.


In the early years of the society, the focus was primarily on the surgical treatment of  arterial occlusive disease . However, over time, the scope of the society's work expanded to include the treatment of all types of vascular disease.


The Society for Vascular Surgery is a professional medical society that represents vascular surgeons in the United States and around the world. The society has over 5,500 members, including vascular surgeons, trainees, and allied health professionals. The society is governed by a board of directors, which is made up of elected members of the society.


The society has several committees that are responsible for various aspects of the society's work, including research, education, advocacy, and quality improvement. The society also has a foundation, the SVS Foundation, which funds research into vascular disease and advocates for improved patient care.


The Society for Vascular Surgery  develops  clinical practice guidelines  for the diagnosis and management of vascular disease. The society's guidelines are developed by expert panels, based on the best available evidence, and are designed to help healthcare providers make informed decisions about the care of patients with vascular disease.


The SVS publishes of the Journal of Vascular Surgery and its associated co-journals. In addition, the society also has an active Patient Safety Organization and Vascular Quality Improvement program.


JVS is a subscription based,  peer reviewed  academic journal published by  Elsevier . It has been in circulation since 1984 and has published several of the most notable academic papers in the field of vascular surgery. [ 2 ]  The journal publishes original research articles, review articles, case reports, and editorials related to the diagnosis, treatment, and prevention of vascular diseases. In 2013, JVS had an impact factor of 2.98. [ 3 ]  In 2014, JVS launched an additional journal, "JVS: Venous and Lymphatic Disorders". [ 4 ]


In addition to the JVS, the SVS also publishes several co-journals:


The SVS Patient Safety Organization (PSO) was established in 2011 as a response to the growing need for improved patient safety in vascular surgery. The PSO is dedicated to improving patient outcomes and reducing medical errors by collecting and analyzing data on adverse events and near misses in vascular surgery. The PSO provides its members with tools and resources to promote a culture of safety and to reduce the risk of medical errors. The organization also conducts research and provides educational programs focused on patient safety.


The SVS Vascular Quality Improvement Program (VQI) was established in 2011. The VQI is a national registry that collects and analyzes data on the outcomes of vascular surgeries performed at participating institutions. The registry enables participating institutions to track their own performance and compare it to national benchmarks. The VQI provides feedback to participating institutions to help them improve patient outcomes and reduce the risk of medical errors. In addition, the VQI conducts research and provides educational programs focused on improving the quality of vascular surgery.


The SVS is governed by a Board of Directors and is supported by a number of committees, task forces, and sections. The Board of Directors is responsible for setting the strategic direction of the society and overseeing its operations. The committees, task forces, and sections are responsible for carrying out specific functions and activities of the society. These include activities such as education, research, advocacy, and quality improvement. The society also has regional chapters and international affiliates that provide additional support to its members.


The SVS offers educational programs and resources for its members. These include the SVS Vascular Annual Meeting and online educational resources, including webinars, podcasts, and online courses.


Subclavian steal syndrome (SSS) , also called  subclavian steal steno-occlusive disease , is a medical condition characterized by retrograde (reversed)  blood flow  in the  vertebral artery  or the  internal thoracic artery . This reversal occurs due to  proximal   stenosis  (narrowing) or occlusion of the  subclavian artery .


The phenomenon of flow reversal is called  subclavian steal  or  subclavian steal  phenomenon, regardless of whether signs or symptoms are present. [ 1 ]  In this condition, the affected arm may receive blood supply flowing in a retrograde direction down the vertebral artery, potentially compromising the vertebrobasilar circulation. Subclavian steal syndrome is considered more severe than typical  vertebrobasilar insufficiency .


There are multiple processes that can cause obstruction of the subclavian artery before the vertebral artery, giving opportunity for SSS.


Atherosclerosis  is the most common cause of SSS; [ 2 ]  all atherosclerotic risk factors are risk factors for SSS.


Thoracic outlet syndrome  (TOS) increases the risk for SSS. [ 2 ]  TOS doesn't directly cause SSS, because the site of subclavian artery compression is over the first rib, which is distal to the vertebral artery. TOS has been reported to cause stroke through theorized clot propagation towards the vertebral artery; [ 3 ]  a similar mechanism could explain how TOS causes SSS. Presence of a  cervical rib  is a risk factor for both TOS and SSS. [ citation needed ]


Takayasu's arteritis  is a disease causing inflammation of arteries, including the subclavian artery. Inflammation leaves behind dense scar tissue, which can become stenotic and restrict blood flow. [ 4 ]


SSS can be  iatrogenic , meaning a complication or side effect of medical treatment, one example being the obstructive fibrosis or thrombosis resulting from repair of  aortic coarctation . [ 5 ]  Another example is  Blalock–Taussig anastomosis  for treatment of  tetralogy of Fallot . The procedure involves dividing the subclavian artery and reconnecting the proximal portion to the  pulmonary arteries , leaving the vertebral artery as the primary supply to the distal subclavian artery. [ 6 ]


Various congenital vascular malformations cause SSS, examples including aortic coarctation and  interrupted aortic arch . [ 7 ]


Classically, SSS is a consequence of a redundancy in the circulation of the brain [ 8 ] [ 9 ]  and the  flow of blood .


SSS results when the short low resistance path (along the subclavian artery) becomes a high resistance path (due to narrowing) and blood flows around the narrowing via the arteries that supply the brain (left and right vertebral artery, left and right internal carotid artery).  The blood flow from the brain to the  upper limb  in SSS is considered to be  stolen  as it is blood flow the brain must do without. This is because of collateral vessels. [ citation needed ]


As in vertebral-subclavian steal,  coronary -subclavian steal may occur in patients who have received a  coronary artery bypass graft  using the  internal thoracic artery  (ITA), also known as internal mammary artery. [ 10 ]  As a result of this procedure, the distal end of the ITA is diverted to one of the coronary arteries (typically the  LAD ), facilitating blood supply to the  heart . In the setting of increased resistance in the proximal subclavian artery, blood may flow backward away from the heart along the ITA, causing  myocardial ischemia  due to  coronary steal . Vertebral-subclavian and  coronary -subclavian steal can occur concurrently in patients with an ITA  CABG . [ 11 ]


Blood, like  electric current , flows along the path of least  resistance . Resistance is affected by the length and width of a vessel (i.e. a long, narrow vessel has the greatest resistance and a short, wide one the least), but crucially, in the human body, width is generally more limiting than length because of  Poiseuille's Law . Thus, if blood is presented with two paths, a short one that is narrow (with a high overall resistance) and a long one that is wide (with a low overall resistance), it will take the long and wide path (the one with the lower resistance). [ citation needed ]


The  blood vessels  supplying the  brain  arise from the  vertebral arteries  and  internal carotid arteries  and are connected to one another by communicating vessels that form a circle (known as the  circle of Willis ). [ citation needed ]


Normally, blood flows from the  aorta  into the subclavian artery, and then some of that blood leaves via the vertebral artery to supply the brain.


In SSS a reduced quantity of blood flows through the proximal subclavian artery.  As a result, blood travels up one of the other blood vessels to the brain (the other vertebral or the carotids), reaches the basilar artery or goes around the cerebral arterial circle and descends via the (contralateral) vertebral artery to the subclavian (with the proximal blockage) and feeds blood to the distal subclavian artery (which supplies the upper limb and shoulder). [ citation needed ]


The evaluation for this condition includes: [ citation needed ]


Management for this condition includes: [ citation needed ]


Blood pressure in toes  can be measured using special equipment, and is often valuable in assessment of severe  peripheral artery disease , in particular in patients with  diabetes  where measurement of  ankle pressure  /  ABPI  is often unreliable (because of local stiffening of arterial wall).


Feet are often cold and to make sure measurement is not affected by local vasoconstriction, the patient's feet may be pre-warmed in water or by warm air to a skin temperature of around 30 °C.
Measurement is done with the patient lying flat, with feet at heart level, using sphygmomanometry: the big toe is slightly emptied of blood by squeezing, and a small cuff is inflated around the base of the toe. Cuff pressure is then slowly lowered until flow can be detected in the distal part of the toe, e.g. by optical means (photocell), by expansion of the toe as measured with  strain gauge plethysmography , or by visual assessment of color change by an experienced examiner, and the pressure at which this occurs is recorded.


The toe pressure is usually slightly lower than arm blood pressure, a difference of up to 50mmHg is considered acceptable. Toe pressures below 30 mmHg (in diabetics 50mmHg) are pathological and associated with reduced viability of the tissue and risk of amputation.


Transjugular intrahepatic portosystemic shunt  ( TIPS  or  TIPSS ) is an artificial channel within the  liver  that establishes communication between the inflow  portal vein  and the outflow  hepatic vein . It is used to treat  portal hypertension  (which is often due to  liver cirrhosis ) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding ( esophageal varices ) and the buildup of fluid within the abdomen ( ascites ).


An  interventional radiologist  creates the shunt using an image-guided  endovascular  (via the  blood vessels ) approach, with the  jugular vein  as the usual entry site.


The procedure was first described by  Josef Rösch  in 1969 at  Oregon Health and Science University . It was first used in a human patient by Dr. Ronald Colapinto, of the  University of Toronto , in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the  University of Freiburg . [ 1 ]  The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical  portacaval shunt  in that role.


TIPS is a life-saving procedure in bleeding from esophageal or gastric varices. A randomized study showed that the survival is better if the procedure is done within 72 hours after  bleeding . [ 2 ]  TIPS has shown some promise for people with  hepatorenal syndrome . [ 3 ]  It may also help with  ascites . [ 4 ]


Severe procedural complications during a TIPS procedure, including catastrophic bleeding or direct liver injury, are relatively uncommon. In the hands of an experienced physician, operative mortality is less than 1% [ medical citation needed ] . On the other hand, up to 25% of patients who undergo TIPS will experience transient post-operative  hepatic encephalopathy  caused by increased porto-systemic passage of nitrogen from the gut. [ 5 ]


A less common, but more serious complication, is hepatic ischemia causing acute liver failure. While healthy livers are predominantly oxygenated by portal blood supply, long-standing portal hypertension results in compensatory hypertrophy of and increased reliance on the hepatic artery for oxygenation. Thus, in people with advanced liver disease the shunting of portal blood away from hepatocytes is usually well tolerated. However, in some cases suddenly shunting portal blood flow away from the liver may result in acute liver failure secondary to hepatic ischemia. [ 6 ]  Acute hepatic dysfunction after TIPS may require emergent closure of the shunt. [ citation needed ]


A rare but serious complication is persistent TIPS infection, also known as endotipsitis. [ 7 ]


Lastly, the TIPS may become blocked by a blood clot or in-growth of endothelial cells and no longer function. This has been significantly reduced with the use of  polytetrafluoroethylene  (PTFE)–covered stents. [ 8 ]


Portal hypertension, an important consequence of liver disease, results in the development of significant  collateral circulation  between the portal system and systemic venous drainage (porto-caval circulation). Portal venous congestion causes venous blood leaving the stomach and intestines to be diverted along auxiliary routes of lesser resistance in order to drain to systemic circulation. With time, the small vessels that comprise a collateral path for porto-caval circulation become engorged and dilated. These vessels are fragile and often hemorrhage into the GI tract. ( See  esophageal ,  gastric ,  rectal varices ). [ citation needed ]


A TIPS procedure decreases the effective  vascular resistance  of the liver through the creation of an alternative pathway for portal venous circulation. By creating a shunt from the portal vein to the hepatic vein, this intervention allows portal blood an alternative avenue for draining into systemic circulation. In bypassing the flow-resistant liver, the net result is a reduced  pressure drop  across the liver and a decreased portal venous pressure. Decreased portal venous pressure in turn lessens congestive pressures along veins in the intestine so that future bleeding is less likely to occur.  The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur. [ citation needed ]


Transjugular intrahepatic portosystemic shunts are typically placed by an interventional radiologist under  fluoroscopic  guidance. [ 9 ]  Access to the liver is gained, as the name 'transjugular' suggests, via the  internal jugular vein  in the  neck .  Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the  shunt 's placement.  This enables the interventional radiologist to gain access to the patient's  hepatic vein  by traveling from the  superior vena cava  into the  inferior vena cava  and finally the  hepatic vein .


Once the catheter is in the hepatic vein, a wedge pressure is obtained to calculate the pressure gradient in the liver. Following this, carbon dioxide is injected to locate the portal vein. Then, a special needle known as a Colapinto is advanced through the liver parenchyma to connect the hepatic vein to the large  portal vein , near the center of the liver.  The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle.  The shunt is completed by placing a special mesh tube known as a  stent  or endograft to maintain the tract between the higher-pressure portal vein and the lower-pressure hepatic vein.  After the procedure, fluoroscopic images are made to show placement. Pressure in the portal vein and inferior vena cava are often measured. [ citation needed ]


Varicose veins , also known as  varicoses , are a medical condition in which  superficial veins  become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain,  itching , and  nighttime leg cramps . [ 1 ] [ 2 ] [ 5 ]  These  veins  typically develop in the legs, just under the skin. [ 3 ]  Their complications can include bleeding,  skin ulcers , and  superficial thrombophlebitis . [ 1 ] [ 2 ]   Varices  in the  scrotum  are known as  varicocele , while those around the  anus  are known as  hemorrhoids . [ 1 ]  The physical, social, and psychological effects of varicose veins can lower their bearers'  quality of life . [ 6 ]


Varicose veins have no specific cause. [ 2 ]  Risk factors include  obesity , lack of exercise, leg trauma, and  family history  of the condition. [ 3 ]  They also develop more commonly during  pregnancy . [ 3 ]  Occasionally they result from  chronic venous insufficiency . [ 2 ]  Underlying causes include weak or damaged valves in the veins. [ 1 ]  They are typically diagnosed by examination, including observation by  ultrasound . [ 2 ]


By contrast,  spider veins  affect the  capillaries  and are smaller. [ 1 ] [ 7 ]


Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance. [ 1 ]  Lifestyle changes may include wearing  compression stockings , exercising, elevating the legs, and weight loss. [ 1 ]  Possible medical procedures include  sclerotherapy ,  laser surgery , and  vein stripping . [ 2 ] [ 1 ]  However, recurrence is common following treatment. [ 2 ]


Varicose veins are very common, affecting about 30% of people at some point in their lives. [ 8 ] [ 3 ] [ 9 ]  They become more common with age. [ 3 ]  Women develop varicose veins about twice as often as men. [ 7 ]  Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius. [ citation needed ]


People with varicose veins might have a positive  D-dimer  blood test result due to chronic low-level thrombosis within dilated veins ( varices ). [ 14 ]


Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.


Varicose veins are more common in women than in men and are linked with  heredity . [ 16 ]  Other related factors are  pregnancy ,  obesity ,  menopause ,  aging , prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles. [ 17 ]  Less commonly, but not exceptionally, varicose veins can be due to other causes, such as  post-phlebitic obstruction  or incontinence, venous and arteriovenous malformations. [ 18 ]


Venous reflux  is a significant cause. Research has also shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux. [ 19 ] [ 20 ]  Both ovarian and internal  iliac vein  reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins. [ 21 ]  In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins. [ 22 ]


There is increasing evidence for the role of incompetent  perforator veins  (or "perforators") in the formation of varicose veins. [ 23 ]  and recurrent varicose veins. [ 24 ]


Varicose veins could also be caused by  hyperhomocysteinemia  in the body, which can degrade and inhibit the formation of the three main structural components of the artery:  collagen ,  elastin  and the  proteoglycans .  Homocysteine  permanently degrades  cysteine   disulfide  bridges and  lysine   amino acid  residues in  proteins , gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e.  collagen  or  elastin , or lifelong proteins, i.e.  fibrillin . These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline.  Klippel–Trenaunay syndrome  and  Parkes Weber syndrome  are relevant for  differential diagnosis . [ citation needed ]


Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity. [ 25 ]


Clinical tests that may be used include: [ citation needed ]


Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using  lower limbs venous ultrasonography . The results from a  randomised controlled trial  on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up. [ 26 ]


The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) Classification, developed in 1994 by an international ad hoc committee of the  American Venous Forum , outlines these stages [ 27 ] [ 28 ]


Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic (S) or asymptomatic (A), e.g. C2S. [ 29 ]


Treatment can be either active or conservative.


Treatment options include surgery,  laser  and   radiofrequency ablation , and ultrasound-guided foam  sclerotherapy . [ 8 ] [ 30 ] [ 31 ]  Newer treatments include  cyanoacrylate  glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit. [ 32 ]


The  National Institute for Health and Clinical Excellence  (NICE) produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins (C2S) and worse should be referred to a vascular service for treatment. [ 33 ]  Conservative treatments such as support stockings should not be used unless treatment was not possible.


The symptoms of varicose veins can be controlled to an extent with the following:


Stripping consists of removal of all or part the saphenous vein ( great/long  or  lesser/short ) main trunk. The complications include  deep vein thrombosis  (5.3%), [ 37 ]   pulmonary embolism  (0.06%), and wound complications including infection (2.2%). There is evidence for the  great saphenous vein  regrowing after stripping. [ 38 ]  For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease). [ 39 ]


Other surgical treatments are:


A commonly performed non-surgical treatment for varicose and "spider leg veins" is  sclerotherapy , in which medicine called a sclerosant is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are  polidocanol  (POL branded Asclera in the United States, Aethoxysklerol in Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), hypertonic saline,  glycerin  and chromated glycerin. STS (branded Fibrovein in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO 2  or O 2  to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial [ medical citation needed ] , and there is no clear evidence that foams are superior. [ 42 ]  Sclerotherapy has been used in the treatment of varicose veins for over 150 years. [ 15 ]  Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping. [ 43 ] [ 44 ]  Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. [ 45 ] [ 46 ]


There is some evidence that sclerotherapy is a safe and possibly effective treatment option for improving the cosmetic appearance, reducing residual varicose veins, improving the quality of life, and reducing symptoms that may be present due to the varicose veins. [ 42 ]  There is also weak evidence that this treatment option may have a slightly higher risk of deep vein thrombosis. It is not known if sclerotherapy decreases the chance of varicose veins returning (recurrent varicose veins). [ 42 ]  It is also not known which type of substance (liquid or foam) used for the sclerotherapy procedure is more effective and comes with the lowest risk of complications. [ 42 ]


Complications of sclerotherapy are rare, but can include blood clots and ulceration.  Anaphylactic  reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready. [ 47 ] [ 48 ]  There has been one reported case of  stroke  after ultrasound-guided sclerotherapy when an unusually large dose of sclerosant foam was injected. [ 49 ]


There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam. [ 50 ]


The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that  endovenous laser treatment /ablation (ELA) for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins." [ 51 ]  It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury, and paraesthesia, post-operative infections, and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for ELA include minor skin burns (0.4%) [ 52 ]  and temporary  paresthesia  (2.1%). The longest study of endovenous laser ablation is 39 months. [ 53 ]


Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery. [ 54 ] [ 55 ]  Myers [ 56 ]  wrote that open surgery for  small saphenous vein  reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. By comparison ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical  phlebitis  and slightly higher rates of  deep vein thrombosis  (0.57%) and  pulmonary embolism  (0.17%). One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%. [ citation needed ]


Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency. [ 57 ]  The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.) [ 58 ]  Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities). [ 59 ]


ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a  general anaesthetic . Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. [ citation needed ]


Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an  ambulatory phlebectomy . The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins. [ 60 ]  Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.


Also called medical super glue, medical adhesive is an advanced non-surgical treatment for varicose veins during which a solution is injected into the diseased vein through a small catheter and under the assistance of ultrasound-guided imagery. The "super glue" solution is made of cyanoacrylate, aiming at sealing the vein and rerouting the blood flow to other healthy veins. [ 61 ]


Post-treatment, the body will naturally absorb the treated vein which will disappear. Involving only a small incision and no hospital stay, medical super glue has generated great interest within the last years, with a success rate of about 96.8%. [ 62 ]


A follow-up consultation is required after this treatment, just like any other one, in order to re-assess the diseased vein and further treat it if needed. [ citation needed ]


In the field of varicose veins, the latest medical innovation is high-intensity focused ultrasound therapy ( HIFU ). This method is completely non-invasive and is not necessarily performed in an operating room, unlike existing techniques. This is because the procedure involves treating from outside the body, able to penetrate the skin without damage, to treat the veins in a targeted area. [ 63 ]  This leaves no scars and allows the patient to return to their daily life immediately.


Varicose veins are most common after age 50. [ 64 ]  It is more prevalent in females. [ 65 ]  There is a hereditary role. It has been seen in smokers, those who have  chronic constipation , and in people with occupations which necessitate long periods of standing such as wait staff, nurses, conductors (musical and bus), stage actors, umpires (cricket, javelin, etc.), the King's guards, lectern orators, security guards, traffic police officers, vendors, surgeons, etc. [ 29 ]


Vascular access steal syndrome  is a  syndrome  caused by  ischemia  (not enough  blood flow ) resulting from a vascular access device (such as an  arteriovenous fistula  or synthetic vascular graft–AV fistula) that was installed to provide access for the inflow and outflow of  blood  during  hemodialysis .


Symptoms are graded by their severity: [ 3 ]


The fistula flow can be restricted through banding, or modulated through surgical revision.


If the above methods fail, the fistula is ligated, and a new fistula is created in a more proximal location in the same limb, or in the contralateral limb.


DASS occurs in about 1% of AV fistulas and 2.7-8% of  PTFE  grafts. [ 12 ] [ 13 ]


Within the  contexts  of nephrology and dialysis, vascular access steal syndrome is also less precisely just called steal syndrome (for short), but in wider contexts that term is ambiguous because it can refer to other steal syndromes, such as  subclavian steal syndrome  or  coronary steal syndrome . [ citation needed ]


Venous cutdown  is an emergency procedure in which the vein is exposed surgically and then a  cannula  is inserted into the vein under direct vision. It is used for  venous access  in cases of  trauma , and  hypovolemic shock  when the use of a  peripheral venous catheter  is either difficult or impossible. The  great saphenous vein  is most commonly used. This procedure has fallen out of favor with the development of safer techniques for  central venous catheterization  such as the  Seldinger technique , the modified Seldinger technique, [ 1 ] [ 2 ] [ 3 ]   intraosseous infusion , as well as the use of ultrasound guidance for placement of central venous catheters without using the cutdown technique. [ 4 ] [ 5 ] [ 6 ]


The skin is cleaned, draped, and  anesthetized  if time allows. The greater saphenous vein is identified on the surface above the medial  malleolus , a full-thickness transverse skin incision is made, and 2 cm of the vein is freed from the surrounding structures. The vessel is tied closed distally, the proximal portion is sliced open (venotomy) and gently dilated, and a cannula is introduced through the venotomy and secured in place with a more proximal ligature around the vein and cannula. An  intravenous  line is connected to the cannula to complete the procedure.


Complications of venous cutdown include  cellulitis ,  hematoma ,  phlebitis , perforation of the posterior wall of the vein,  venous thrombosis  and nerve and arterial transection. This procedure can result in damage to the  saphenous nerve  due to its intimate path with the great saphenous vein, resulting in loss of cutaneous sensation in the medial leg. Over the years, the venous cutdown procedure has become outdated by the introduction and recent prehospital developments of  intraosseous infusion  in trauma/hypovolemic shock patients.


Venous stasis , or  venostasis ,  is a condition of slow  blood  flow in the  veins , usually of the legs.


Potential complications of venous stasis are:


Causes [ 2 ]  of venous stasis include:


Ultrasonography-Doppler ultrasound


Orthopedic surgery  or  orthopedics  ( alternative spelling   orthopaedics ) is the branch of  surgery  concerned with conditions involving the  musculoskeletal system . [ 1 ]  Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal  trauma ,  spine diseases ,  sports injuries ,  degenerative diseases , infections,  tumors , and  congenital disorders .


Nicholas Andry  coined the word in French as  orthopédie , derived from the  Ancient Greek  words  ὀρθός   orthos  ("correct", "straight") and  παιδίον   paidion  ("child"), and published  Orthopedie  (translated as  Orthopædia: Or the Art of Correcting and Preventing Deformities in Children [ 2 ] ) in 1741. The word was  assimilated  into English as  orthopædics ; the  ligature   æ  was common in that era for  ae  in Greek- and Latin-based words. As the name implies, the discipline was initially developed with attention to children, but the correction of spinal and bone deformities in all stages of life eventually became the cornerstone of orthopedic practice. [ citation needed ]


As with many words derived with the  "æ" ligature , simplification to either "ae" or just "e" is common, especially in North America. In the US, the majority of college, university, and residency programmes, and even the  American Academy of Orthopaedic Surgeons , still use the spelling with the digraph  ae , though hospitals usually use the shortened form. Elsewhere, usage is not uniform; in Canada, both spellings are acceptable; "orthopaedics" is the normal spelling in the UK in line with other fields which retain "ae". [ citation needed ]


Many developments in orthopedic surgery have resulted from experiences during wartime. [ 3 ]  On the battlefields of the  Middle Ages , the injured were treated with bandages soaked in horses' blood, which dried to form a stiff, if unsanitary, splint. [ citation needed ]


Originally, the term orthopedics meant the correcting of musculoskeletal deformities in children. [ 4 ]   Nicolas Andry , a professor of medicine at the  University of Paris , coined the term in the first textbook written on the subject in 1741. He advocated the use of exercise, manipulation, and splinting to treat deformities in children. His book was directed towards parents, and while some topics would be familiar to orthopedists today, it also included 'excessive sweating of the palms' and freckles. [ 5 ]


Jean-André Venel  established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He developed the club-foot shoe for children born with foot deformities and various methods to treat curvature of the spine. [ citation needed ]


Advances made in surgical technique during the 18th century, such as  John Hunter 's research on  tendon  healing and  Percival Pott 's work on  spinal deformity  steadily increased the range of new methods available for effective treatment.  Robert Chessher , a pioneering British orthopedist, invented the double-inclined plane, used to treat lower-body bone fractures, in 1790. [ 6 ]   Antonius Mathijsen , a Dutch military surgeon, invented the  plaster of Paris   cast  in 1851. Until the 1890s, though, orthopedics was still a study limited to the correction of deformity in children. One of the first surgical procedures developed was percutaneous tenotomy. This involved cutting a tendon, originally the Achilles tendon, to help treat deformities alongside bracing and exercises. In the late 1800s and first decades of the 1900s, significant controversy arose about whether orthopedics should include surgical procedures at all. [ citation needed ]


Examples of people who aided the development of modern orthopedic surgery were  Hugh Owen Thomas , a surgeon from  Wales , and his nephew,  Robert Jones . [ 7 ]  Thomas became interested in orthopedics and  bone-setting  at a young age, and after establishing his own practice, went on to expand the field into the general treatment of fracture and other musculoskeletal problems. He advocated enforced rest as the best remedy for  fractures  and  tuberculosis , and created the so-called "Thomas splint" to stabilize a fractured femur and prevent infection. He is also responsible for numerous other medical innovations that all carry his name: Thomas's collar to treat tuberculosis of the cervical spine, Thomas's maneuvere, an orthopedic investigation for fracture of the hip joint, the  Thomas test , a method of detecting hip deformity by having the patient lying flat in bed, and Thomas's wrench for reducing fractures, as well as an  osteoclast  to break and reset bones. [ citation needed ]


Thomas's work was not fully appreciated in his own lifetime. Only during the  First World War  did his techniques come to be used for injured soldiers on the  battlefield . His nephew, Sir Robert Jones, had already made great advances in orthopedics in his position as surgeon-superintendent for the construction of the  Manchester Ship Canal  in 1888. He was responsible for the injured among the 20,000 workers, and he organized the first comprehensive accident service in the world, dividing the 36-mile site into three sections, and establishing a hospital and a string of first-aid posts in each section. He had the medical personnel trained in fracture management. [ 8 ]  He personally managed 3,000 cases and performed 300 operations in his own hospital. This position enabled him to learn new techniques and improve the standard of fracture management. Physicians from around the world came to Jones' clinic to learn his techniques. Along with Alfred Tubby, Jones founded the British Orthopedic Society in 1894.


During the First World War, Jones served as a  Territorial Army  surgeon. He observed that treatment of fractures both, at the front and in hospitals at home, was inadequate, and his efforts led to the introduction of military orthopedic hospitals. He was appointed Inspector of Military Orthopedics, with responsibility for 30,000 beds. The hospital in Ducane Road,  Hammersmith , became the model for both British and American military orthopedic hospitals. His advocacy of the use of  Thomas splint  for the initial treatment of  femoral  fractures reduced mortality of open fractures of the femur from 87% to less than 8% in the period from 1916 to 1918. [ 9 ]


The use of  intramedullary rods  to treat fractures of the femur and  tibia  was pioneered by  Gerhard Küntscher  of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during  World War II  and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world.  Traction  was the standard method of treating thigh bone fractures until the late 1970s, though, when the  Harborview Medical Center  group in Seattle popularized intramedullary fixation without opening up the fracture.


The modern total  hip replacement  was pioneered by Sir  John Charnley , expert in  tribology  at  Wrightington Hospital , in England in the 1960s. [ 10 ]  He found that joint surfaces could be replaced by implants cemented to the bone. His design consisted of a  stainless steel , one-piece femoral stem and head, and a  polyethylene  acetabular component, both of which were fixed to the bone using  PMMA  (acrylic)  bone cement . For over two decades, the Charnley low-friction arthroplasty and its derivative designs were the most-used systems in the world. This formed the basis for all modern hip implants.


The  Exeter  hip replacement system (with a slightly different stem geometry) was developed at the same time. Since Charnley, improvements have been continuous in the design and technique of  joint replacement  (arthroplasty) with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant.


Knee replacements, using similar technology, were started by McIntosh in  rheumatoid arthritis  patients and later by Gunston and Marmor for  osteoarthritis  in the 1970s, developed by  John Insall  in New York using a fixed bearing system, and by Frederick Buechel and Michael Pappas using a mobile bearing system. [ 11 ]


External fixation of fractures was refined by American surgeons during the  Vietnam War , but a major contribution was made by  Gavril Abramovich Ilizarov  in the  USSR . He was sent, without much orthopedic training, to look after injured Russian soldiers in  Siberia  in the 1950s. With no equipment, he was confronted with crippling conditions of unhealed, infected, and misaligned fractures. With the help of the local bicycle shop, he devised ring external  fixators  tensioned like the spokes of a bicycle. With this equipment, he achieved healing, realignment, and  lengthening  to a degree unheard of elsewhere. His  Ilizarov apparatus  is still used today as one of the distraction osteogenesis methods. [ 12 ]


Modern orthopedic surgery and musculoskeletal research have sought to make surgery less invasive and to make implanted components better and more durable. On the other hand, since the emergence of the opioid epidemic, orthopedic surgeons have been identified as one of the highest prescribers of opioid medications. [ 13 ] [ 14 ]  Decreasing prescription of opioids while still providing adequate pain control is a development in orthopedic surgery. [ 14 ] [ 15 ] [ 16 ]


In the United States, orthopedic surgeons have typically completed four years of undergraduate education and four years of medical school and earned either a  Doctor of Medicine  (MD) or  Doctor of Osteopathic Medicine  (DO) degree. Subsequently, these medical school graduates undergo  residency  training in orthopedic surgery. The five-year residency is a categorical orthopedic surgery training.


Selection for residency training in orthopedic surgery is very competitive. Roughly 700 physicians complete orthopedic residency training per year in the United States. About 10% of current orthopedic surgery residents are women; about 20% are members of minority groups. Around 20,400 actively practicing orthopedic surgeons and residents are in the United States. [ 17 ]  According to the latest Occupational Outlook Handbook (2011–2012) published by the  United States Department of Labor , 3–4% of all practicing physicians are orthopedic surgeons.