Vascular & Venous Surgery

Immediate IV unfractionated heparin bolus (80 U/kg + 18 U/kg/h infusion) and bedside handheld arterial/venous Doppler to stage by Rutherford Class: Class I (viable, no sensory/motor loss) & Class IIa (marginally threatened, minimal toe sensory loss, no motor weakness): urgent CTA and catheter-directed thrombolysis/percutaneous mechanical thrombectomy or open revascularization. Class IIb (immediately threatened: rest pain, sensory loss beyond toes, mild-to-moderate motor weakness): EMERGENCY operating room thromboembolectomy (Fogarty catheter with intraoperative completion angiography) or bypass + low threshold for 4-compartment fasciotomy. Class III (irreversible: profound paralysis/rigor, anesthesia, inaudible arterial & venous Doppler): primary amputation without revascularization.

Before: Delaying anticoagulation or sending a patient with Rutherford Class IIb motor deficit for prolonged diagnostic angiography/catheter thrombolysis.

Now: Immediate IV unfractionated heparin bolus (80 U/kg + 18 U/kg/h infusion) and bedside handheld arterial/venous Doppler to stage by Rutherford Class: Class I (viable, no sensory/motor loss) & Class IIa (marginally threatened, minimal toe sensory loss, no motor weakness): urgent CTA and catheter-directed thrombolysis/percutaneous mechanical thrombectomy or open revascularization. Class IIb (immediately threatened: rest pain, sensory loss beyond toes, mild-to-moderate motor weakness): EMERGENCY operating room thromboembolectomy (Fogarty catheter with intraoperative completion angiography) or bypass + low threshold for 4-compartment fasciotomy. Class III (irreversible: profound paralysis/rigor, anesthesia, inaudible arterial & venous Doppler): primary amputation without revascularization.

Acute Limb Ischemia (ALI <14 days duration: sudden pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis).

Skeletal muscle tolerates warm ischemia for only 4–6 hours; in Class IIb motor deficit, catheter thrombolysis takes 12–24 hours (too slow to save muscle), whereas in Class III rigor, revascularization triggers lethal hyperkalemic/myoglobinuric reperfusion arrest.

• ESVS 2020 Acute Limb Ischemia Clinical Practice Guidelines (Björck et al.) — as cited in Addendum §11.1

Stage limb threat by SVS WIfI and map ipsilateral/contralateral Great Saphenous Vein (GSV) by duplex ultrasound first: (1) In fit surgical candidates with infrainguinal femoropopliteal/tibial CLTI who possess an adequate single-segment GSV (≥3.0 mm), open GSV surgical bypass provides superior durability and lower major adverse limb events (BEST-CLI Cohort 1); (2) In patients lacking an adequate single-segment GSV (BEST-CLI Cohort 2), high-risk frail patients, or isolated infrapopliteal crural disease (BASIL-2), perform endovascular-first revascularization; pair all patients with high-intensity statin, antiplatelet (or low-dose rivaroxaban 2.5 mg BID + aspirin 81–100 mg per VOYAGER-PAD), smoking cessation, and glycemic control.

Before: Dogmatic 'endovascular-first for everyone' without mapping saphenous vein conduit quality, or performing prosthetic femoropopliteal/tibial bypass when endovascular options exist.

Now: Stage limb threat by SVS WIfI and map ipsilateral/contralateral Great Saphenous Vein (GSV) by duplex ultrasound first: (1) In fit surgical candidates with infrainguinal femoropopliteal/tibial CLTI who possess an adequate single-segment GSV (≥3.0 mm), open GSV surgical bypass provides superior durability and lower major adverse limb events (BEST-CLI Cohort 1); (2) In patients lacking an adequate single-segment GSV (BEST-CLI Cohort 2), high-risk frail patients, or isolated infrapopliteal crural disease (BASIL-2), perform endovascular-first revascularization; pair all patients with high-intensity statin, antiplatelet (or low-dose rivaroxaban 2.5 mg BID + aspirin 81–100 mg per VOYAGER-PAD), smoking cessation, and glycemic control.

Revascularization strategy in Chronic Limb-Threatening Ischemia (CLTI: rest pain, non-healing ulcer >2 weeks, or gangrene).

In BEST-CLI Cohort 1 (n = 1,434 with adequate single-segment GSV), surgical bypass reduced major adverse limb events or death vs. endovascular therapy (42.6% vs. 57.4%, HR 0.68, p < 0.001) and lowered major amputation (10.4% vs. 14.9%); in BASIL-2 (n = 345 infrapopliteal CLTI), best endovascular treatment improved amputation-free survival over vein bypass (HR 1.35, p = 0.037).

Saudi & Gulf frame (§11.0): routine bilateral lower-extremity venous duplex mapping prior to any CABG/CLTI conduit harvest — the same map-the-vein-first discipline this card carries.

• BEST-CLI Trial — Farber A et al., N Engl J Med 2022 (PMID 36342173; Ref. 94)
• BASIL-2 Trial — Bradbury AW et al., Lancet 2023 (PMID 37116524; Ref. 95)

Preoperative bilateral upper-extremity arterial and venous duplex mapping (target cephalic/basilic vein ≥2.5 mm and radial/brachial artery ≥2.0 mm without central venous stenosis) following the distal-to-proximal 'ESKD Life-Plan': (1) distal radiocephalic (Brescia-Cimino) autogenous AVF first; (2) brachiocephalic AVF second; (3) two-stage brachiobasilic transposition AVF third; and (4) prosthetic AV graft only when autogenous veins are exhausted. For severe Grade III–IV dialysis access-associated steal syndrome (rest pain/digital ulceration), preserve the fistula using Distal Revascularization and Interval Ligation (DRIL), Revision Using Distal Inflow (RUDI), or Proximalization of Arterial Inflow (PAI) rather than simple fistula ligation.

Before: Long-term tunneled central venous catheters or upfront synthetic PTFE arteriovenous grafts in patients with suitable native veins.

Now: Preoperative bilateral upper-extremity arterial and venous duplex mapping (target cephalic/basilic vein ≥2.5 mm and radial/brachial artery ≥2.0 mm without central venous stenosis) following the distal-to-proximal 'ESKD Life-Plan': (1) distal radiocephalic (Brescia-Cimino) autogenous AVF first; (2) brachiocephalic AVF second; (3) two-stage brachiobasilic transposition AVF third; and (4) prosthetic AV graft only when autogenous veins are exhausted. For severe Grade III–IV dialysis access-associated steal syndrome (rest pain/digital ulceration), preserve the fistula using Distal Revascularization and Interval Ligation (DRIL), Revision Using Distal Inflow (RUDI), or Proximalization of Arterial Inflow (PAI) rather than simple fistula ligation.

Hemodialysis vascular access planning and management of access-related hand ischemia (steal syndrome) or pseudoaneurysm.

Autogenous AV fistulas have 3-to-5-fold higher long-term patency and 5-to-10-fold lower infection rates than prosthetic grafts or tunneled catheters; DRIL resolves digital ischemia in >85–90% of patients while salvaging the dialysis access.

Saudi & Gulf frame (§11.0): regional dialysis access care follows the same 'Fistula-First / ESKD Life-Plan' principle this card carries — autogenous radiocephalic/brachiocephalic AV fistula creation.

• NKF-KDOQI Vascular Access Clinical Practice Guidelines — as cited in Addendum §11.1
• ESVS Vascular Access Guidelines — as cited in Addendum §11.1

Triage by 'Hard Signs' of arterial injury (pulsatile hemorrhage, expanding hematoma, thrill/bruit, or absent distal pulses/cold pale limb) vs. 'Soft Signs' (history of hemorrhage, stable hematoma, proximity wound, nerve deficit) and Injured Extremity Index (IEI / ABI): Hard signs proceed directly to operative exploration (or hybrid OR). Soft signs or ABI allow safe observation where significant injury is excluded (except in posterior knee dislocation, where CTA/serial duplex is prudent). In combined vascular + unstable orthopedic trauma with warm ischemia approaching 4–6 hours, place a temporary intravascular shunt (TIVS) first to restore pedal perfusion during external fixation, followed by reversed contralateral saphenous vein interposition graft and prophylactic 4-compartment fasciotomy.

Before: Mandatory formal catheter angiography for all proximity wounds, or delaying vascular restoration during prolonged complex orthopedic fixation.

Now: Triage by 'Hard Signs' of arterial injury (pulsatile hemorrhage, expanding hematoma, thrill/bruit, or absent distal pulses/cold pale limb) vs. 'Soft Signs' (history of hemorrhage, stable hematoma, proximity wound, nerve deficit) and Injured Extremity Index (IEI / ABI): Hard signs proceed directly to operative exploration (or hybrid OR). Soft signs or ABI allow safe observation where significant injury is excluded (except in posterior knee dislocation, where CTA/serial duplex is prudent). In combined vascular + unstable orthopedic trauma with warm ischemia approaching 4–6 hours, place a temporary intravascular shunt (TIVS) first to restore pedal perfusion during external fixation, followed by reversed contralateral saphenous vein interposition graft and prophylactic 4-compartment fasciotomy.

Peripheral extremity arterial trauma (penetrating or blunt knee/elbow dislocation with vascular compromise).

ABI ≥0.90 safely excludes clinically significant extremity arterial injury without invasive angiography; temporary vascular shunting restores distal perfusion within minutes while orthopedic stability is established, cutting amputation rates in half.

• EAST / WTA Peripheral Vascular Trauma Guidelines — as cited in Addendum §11.1

Outpatient Endovenous Thermal Ablation — Endovenous Laser Ablation (EVLA, 1470 nm radial fiber) or Radiofrequency Ablation (RFA) — performed under duplex ultrasound guidance and perivenous tumescent local anesthesia (non-thermal cyanoacrylate adhesive closure or ultrasound-guided foam sclerotherapy [UGFS] as second-line/adjunctive options; open surgery reserved only when endovenous equipment is unavailable or veins are extreme >20–25 mm tortuous aneurysms).

Before: Open surgical saphenofemoral/saphenopopliteal high ligation and stripping under general or spinal anesthesia as routine first-line therapy.

Now: Outpatient Endovenous Thermal Ablation — Endovenous Laser Ablation (EVLA, 1470 nm radial fiber) or Radiofrequency Ablation (RFA) — performed under duplex ultrasound guidance and perivenous tumescent local anesthesia (non-thermal cyanoacrylate adhesive closure or ultrasound-guided foam sclerotherapy [UGFS] as second-line/adjunctive options; open surgery reserved only when endovenous equipment is unavailable or veins are extreme >20–25 mm tortuous aneurysms).

Symptomatic Great Saphenous Vein (GSV) or Small Saphenous Vein (SSV) axial reflux (CEAP C2–C5 varicose veins and skin changes).

EVLA and RFA achieve 92–96% 5-year anatomical occlusion equivalent to open stripping while markedly reducing groin hematoma, wound infection, saphenous/sural nerve injury, pain, and time to return to work.

Saudi & Gulf frame (§11.0): the regional practice adaptation integrates routine bilateral lower-extremity venous duplex mapping prior to any varicose vein ablation or CABG/CLTI conduit harvest.

• ESVS 2022 Chronic Venous Disease Guidelines — De Maeseneer MG et al. (PMID 35027279; Ref. 92)
• CLASS Trial — as cited in Addendum §11.1

Verify adequate arterial inflow first (ABI ≥0.8; modified reduced compression 20–25 mmHg if ABI 0.6–0.8; no tight compression if ABI <0.6), apply multilayer compression therapy (30–40 mmHg), AND perform early endovenous ablation of incompetent superficial truncal/perforator veins within 2 weeks of presentation.

Before: Multilayer compression bandaging alone, deferring superficial venous ablation until after the ulcer has completely healed.

Now: Verify adequate arterial inflow first (ABI ≥0.8; modified reduced compression 20–25 mmHg if ABI 0.6–0.8; no tight compression if ABI <0.6), apply multilayer compression therapy (30–40 mmHg), AND perform early endovenous ablation of incompetent superficial truncal/perforator veins within 2 weeks of presentation.

Active venous leg ulceration (CEAP C6) with duplex-confirmed superficial venous reflux.

In EVRA (n = 450 randomized 1:1), early endovenous ablation within 2 weeks shortened median time to ulcer healing from 82 days to 56 days (HR 1.42, 95% CI 1.16–1.73; p = 0.001), raised 24-week healing to 85.6% vs. 76.3%, and increased ulcer-free time at 1 year.

Saudi & Gulf frame (§11.0): ankle-brachial/toe-pressure screening before applying compression therapy for leg ulcers in diabetic patients (2026 GCC Diabetic & Vascular Limb Salvage Consensus; Ref. 87).

• EVRA Trial — Gohel MS et al., N Engl J Med 2018 (PMID 29688123; Ref. 93)
• ESVS 2022 Chronic Venous Disease Guidelines (PMID 35027279; Ref. 92)