Vascular Surgery

Overview

Vascular surgery is the surgical specialty that focuses on the vascular system — blood vessels, large and small — as well as the lymphatic system, which moves infection-fighting white blood cells through the body.

Vascular surgery can be necessary to treat many different types of vascular disease, some of which are life-threatening.

Other conditions that often require vascular surgery include:

• Acute (severe/quick onset) deep vein thrombosis: These are also known as blood clots.
• Aortic aneurysms: This can occur in the chest (thoracic aortic aneurysm) or in the abdomen (abdominal aortic aneurysm).
• Critical limb ischemia: This is the loss of blood flow in the limbs, usually caused by peripheral artery disease (PAD). PAD is a condition involving the blockage of an artery that supplies blood to the legs, arms, head, or abdomen, usually caused by atherosclerosis.
• Diabetes vascular disease: The hardening of the arteries throughout the body, caused by diabetes, which can lead to the need for a limb salvage procedure.1
• Dialysis graft and fistula management: A procedure aimed at creating venous access for dialysis.
• Non-healing wounds caused by vascular disease: Such as peripheral vascular disease (PVD), which is a blood circulation disorder involving the blockage or narrowing of any blood vessel outside of the heart and brain.
• Peripheral artery disease: When the arteries of the legs, arms, head, or abdomen become blocked or narrowed.
• Thoracic outlet syndrome: A condition that causes pain and numbness in the arms.
• Varicose veins: A condition involving weakening of the valves in the veins, usually occurs in the veins in the lower legs.
• Vascular malformations: Abnormal connections between blood and lymph vessels.
• Visceral artery disease: Diseased visceral arteries, which supply blood to the intestines, liver, and spleen.
• Lymphaticovenous anastomosis: A surgical procedure that connects a lymphatic vessel to a vein.

Why Its Done

In some instances, emergency vascular surgery—such as the repair of an aortic aneurysm—must be performed to save a person’s life; in yet other scenarios, vascular surgery is done to relieve pain and help improve the quality of life. A good example is a common type of vascular procedure called a carotid endarterectomy, involving the removal of plaques—that occur due to atherosclerosis—from the carotid arteries, to prevent a stroke. Atherosclerosis, which used to be called hardening of the arteries, is a vascular condition involving plaques that adhere to the arteries, eventually occluding or narrowing the blood vessel and inhibiting proper blood flow.

In addition to various types of vascular procedures, there are basically two classifications that describe surgical vascular treatment, these include: 2

• Open surgery: Traditional surgery, which involves a long incision to provide a wide view and direct access to the vein, artery, or other vascular area. Open surgery is more invasive than endovascular surgery.
• Endovascular surgery: A minimally invasive procedure performed using long, thin tubes called catheters, which are inserted into the blood vessels through very small incisions in the skin. An example is an “endovascular stent graft procedure,” which is used to treat an aortic aneurysm. The graft is comprised of a special fabric tube device with self-expanding stents, which are inserted into the arteries (inside of a catheter), which is positioned inside the aorta. Once the graft is placed, it expands, sealing off the ballooned area (aneurysm) of the aorta. The graft remains in the aorta permanently. Minimally invasive procedures are associated with quicker recovery times and a lower risk of surgical complications.

In some complex vascular conditions, a combination of open and minimally invasive procedures are employed during the same operation.

When it comes to vascular surgery, there are many types of procedures that are performed. But among the most common are aortic aneurysm repair, carotid endarterectomy, and bypass surgery, which is performed for deep vein thrombosis. The criteria for common types of vascular surgery include the preset parameters for conditions such as a blockage of the carotid artery, an aortic aneurysm, and bypass surgery for a blockage of a peripheral artery.

Carotid Endarterectomy

Why It’s Done
There are several reasons that a carotid endarterectomy is done, including:3

• A moderate (approximately 50 to 79%) blockage of a carotid artery along with symptoms of a stroke.
• A transient ischemic attack (TIA) that involves symptoms of a stroke such as speech or vision problems or numbness of the face that are temporary.
• A severe (80% or more) blockage of a carotid artery, with or without symptoms.

Criteria for a Carotid Endarterectomy
More specifically, according to the American Heart Association, the criteria for a carotid endarterectomy, for those who are considered a good surgical risk—which considers factors such as exercise tolerance and the existence of conditions such as angina and more—include:4

• One or more TIA’s in the last 6 months and carotid stenosis (narrowing of the carotid artery) of more than 60%.
• Mild stroke within the last 6 months and carotid artery stenosis of over 60%.

It’s important to note the criteria for having a carotid endarterectomy procedure fluctuates under certain circumstances, such as a person’s surgical risk and factors like the potential for acute rupture of an atherosclerotic plaque. Ruptured atherosclerotic plaques can release blood clots that can cause a fatal condition called acute coronary syndrome (ACS).4

Abdominal Aortic Aneurysm Repair

Why It’s Done
Reasons that may indicate that an abdominal aortic aneurysm repair is necessary include:5

• Potential rupture of the abdominal aorta
• Blockage of blood flow through the abdominal aorta
• When the risk of a ruptured abdominal aneurysm is greater than any surgical risks posed by performing the procedure
• To repair bleeding that is considered an emergency, life-threatening situation
• To relieve symptoms such as deep, unrelenting pain or discomfort in the abdomen or back pain

Criteria for an Abdominal Aortic Aneurysm (AAA) Repair
A ruptured AAA is a fatal condition unless emergency surgery is performed immediately. Because of the high mortality (death) rate associated with ruptured aortic aneurysms—both abdominal aneurysms as well as thoracic aneurysms—the overall goal of treatment is to prevent ruptures. Criteria for surgical intervention, based on clinical research studies, include:6

• The larger the AAA, the higher the risk of rupture.
• An AAA that measures over 2.16 inches (5.5 cm) in diameter
• An abdominal aneurysm that is growing more than 0.2 inches (0.5 cm) in a 12-month time span

Peripheral Artery Bypass

Why It’s Done
Peripheral artery bypass surgery is performed to re-route the supply of blood to bypass the diseased or blocked artery; it’s usually done because fatty deposits (called plaques) prohibited blood to flow to the extremities (usually the legs). You may need a peripheral artery bypass if you:7

• Have skin ulcers (sores) or wounds that will not heal
• Your symptoms do not improve with other treatment modalities such as lifestyle changes, like smoking cessation or medication.
• Less invasive treatments such as stenting—a minimally invasive surgical procedure to place a stent in a vessel to keep in open—or angioplasty—a procedure aimed at repairing a diseased blood vessel—have not been successful.
• Your symptoms interfere with activities of daily living such as dressing or bathing.

Criteria for Peripheral Artery Bypass Surgery
The criteria for having peripheral artery bypass surgery differs according to the precise location (artery) that is blocked. The recommendation of whether to have open surgery or endovascular procedure also varies according to several different factors.8 It’s important to talk to your surgeon or vascular specialist about your specific type of peripheral artery disease to find out what exactly the parameters are for having surgical treatment.

Risk

Complications after open vascular surgery are a major health challenge for the healthcare system and the patients. Infrainguinal vascular surgery is often perceived as less risky than aortic surgery and the aim of this study was to identify which risk factors correlated with postoperative complications after open vascular surgery for infrainguinal occlusive disease in an 8-year cohort using the Danish National Vascular Registry (Karbase), which gathers information on all vascular procedures in Denmark.

Some of these risks include bleeding, heart attack and stroke. It is important to discuss them with your vascular surgeon. If you are a smoker, suffer from high blood pressure, have a chronic lung or kidney disease, or other illnesses, you are at a greater risk of developing complications during and after surgery.

How To Prepare For a vascular surgery

Whether you are having a procedure to have your varicose veins repaired, or a major type of vascular surgery, your surgeon will give you a list of specific guidelines on how to prepare for your vascular surgery. There are some general guidelines that pertain to getting ready for most types of vascular surgery, but first and foremost, always follow your surgeon’s instructions.

What You Can Expect

Before procedure

Here are the steps to take before any type of vascular surgery:

• Abstain from eating or drinking: You should abstain from food and drink after midnight the night before your surgery. This includes water and medication—unless otherwise instructed by your healthcare provider.
• Take a special shower: This is done as instructed by a healthcare professional the night before—and again the morning of—your surgery using a special type of antibacterial soap.1
• Only take the medications that your healthcare provider instructed you to take: This will be included in your preoperative instructions, which should have been given to you in writing before your surgery.
• Perform regular oral care: Brush your teeth on the morning of surgery.
• Remove all makeup: Avoid hairspray, lotions, or body oils on the day of surgery.
• Take out any piercings: This includes earrings, nose rings, belly button jewelry, and any other type of jewelry for piercings elsewhere in the body. Don’t wear or bring rings, jewelry, and/or other valuables.
• Pack some comfortable, loose-fitting clothing: You can bring a robe and skid-resistant slippers with you to wear after your procedure.
• Ensure that you have any legal documents with you: This includes power of attorney or guardianship paperwork.
• Bring your photo ID: A passport or your driver’s license will work.
• Bring a list of all medications you take: Be sure to include the dosage and schedule for each drug, vitamin, supplement, herbal medicine, or any other medication you take—including topical skin lotions, creams, or eye drops.
• Remove your contact lenses: Do this at home if you have glasses for a backup, otherwise, you will need to remove them before surgery.
• Take your glasses, hearing aids, and dentures: Be sure to bring with you any carrying cases to store prosthetics and other sensory devices during your surgical procedure.
• Bring any assistive devices: If you use a CPAP machine, make sure you take it to the hospital if you will be staying overnight.

During Procedure

Each type of vascular surgery procedure will differ according to the specific steps involved.

Here is what you would expect if you are having a carotid endarterectomy:2

1. You will be taken to the surgical suite and positioned on your back supine (lying down), with your head turned to the side so your operative carotid artery will face upward.
2. You will be given medication to help you relax.
3. You will receive medicine to put you to sleep in your IV or local anesthesia to numb the area being operated on instead of general anesthesia.
4. Your surgical area will be cleaned with a surgical cleansing solution.
5. The surgeon will make an incision on your neck in the area over the carotid artery.
6. A catheter (flexible tube) might be placed into the artery.
7.  Blood circulates through the catheter and around the blocked area to continue providing adequate oxygenation to the brain during the surgery.
8. An incision is made to open the carotid artery and the surgeon removes the plaque inside the blood vessel.
9. The carotid artery is sewn shut with stitches or closed by using a patch graft (a patch made with a vein or artificial material).
10.  Blood can now flow freely through the artery to the brain.

Note, a different technique, called an eversion carotid endarterectomy, may be used. This procedure involves turning the carotid artery inside out, removing the plaque, then reattaching the artery.

The entire procedure takes approximately two hours. After your procedure is over, your surgeon may perform an imaging test (such as an angiogram) to ensure that the artery is open and that the surgery was successful.

After The Procedure

After surgery, you will go to the recovery area, where you will be closely monitored.

For a major procedure, you may recover in the hospital, possibly in the intensive care unit (ICU), for several days.

If you are having a procedure that is considered minor, such as a venous ligation and stripping procedure, it will likely be done on an outpatient basis. In this instance, you would not be transferred to the ICU, nor would you have an overnight stay in the hospital. If there are no complications, you might be discharged to your home on the day of surgery after a minor vascular surgical procedure.

Results

Usually patients notice results right away. A lot of it depends on the degree or severity of their disease. Some people have such extensive blockages in their legs that they can go on to develop gangrene. That can be a real threat to limb loss, and they could go on to require an amputation. Oftentimes, we do procedures to really preserve limbs and make wound healing a real potential in these patients. But for people who have pain with exertion, they will notice an immediate effect.