UC UC SF SF Emergency Vascular Surgery 41 year old female - PowerPoint PPT Presentation

UC UC SF SF Emergency Vascular Surgery • 41 year old female brought in by ambulance • Massive bright red vaginal bleeding Case Presentation: • HR 120 SBP 85 Temp 38.4 Emergency Vascular Surgery • Access, fluids • 4U pRBC 4UFFP • Vaginal packing • To CT scanner Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Emergency Vascular Surgery Emergency Vascular Surgery • Cervical squamous cell carcinoma - Primary inadquately treated with radiation in foreign country - TAH + BSO - Pelvic exenteration - External beam radiation therapy - Periaortic and iliac lymphadenectomy - External beam radiation therapy - Ileal conduit for ureteral strictures - Enterovaginal fistula unresponsive to percutaneous drainage - Enteric bypass and end colostomy • On coumadin for DVT VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1

UC UC SF SF Emergency Vascular Surgery What would you do? A. Trans-abdominal exposure, packing, resuscitation in ICU B. Angiogram, covered stent across mycotic aneurysm C. Retroperitoneal exposure, ligation and debridement of extrenal iliac artery, fem-fem bypass 0% 0% 0% VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 10 UC UC SF SF Emergency Vascular Surgery Emergency Vascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2

UC UC SF SF Emergency Vascular Surgery What would you do? A. Ilio-femoral bypass • Total 12U PRBC, 12U FFP and 2U Plt B. Angiogram, mechanical thrombolysis • Coagulopathy reversed, hemodynamically stable • Transferred to the floor C. Fem-fem bypass with bilateral sartorius flaps D. Angiogram, pharmaco-mechanical thrombolysis • POD #2 sudden onset left foot pain and parasthesias • On exam, non-palpable femoral pulse, foot palor, mild parasthesias. - No motor deficit - Monophasic doppler signals • Significant flank and groin edema from massive 0% 0% 0% 0% transfusion • Fibrotic skin in groin (presumably from XR) VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 10 UC UC SF SF Emergency Vascular Surgery Emergency Vascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3

UC UC SF SF Emergency Vascular Surgery Emergency Vascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Emergency Vascular Surgery Emergency Vascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4

UC SF Emergency Vascular Surgery • Debridement of infected iliac artery • Irrigation and drainage of pelvic abscess • Wound healed • Converted single remaining surgical drain to pigtail catheter • Resuming tumor surveillance with no evidence of recurrence on last PET/CT • Persistent enterovaginal fistula VASCULAR SURGERY • UC SAN FRANCISCO 5