Vascular surgery.html



Vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The specialty evolved from general and cardiac surgery. Edwin Wylie of San Francisco was one of the early pioneers in the specialty who developed and fostered advanced training in vascular surgery and pushed for its recognition as a specialty in the United States in the 1960's and 1970's. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system except that of the heart and brain. Cardiothoracic surgeons manage surgical disease of the heart and its vessels. Neurosurgeons manage surgical disease of the vessels in the brain (eg intracranial aneurysms).

Breadth of discipline

• Arterial diseases ( especially in Diabetics )
  • Aneurysms
  • Ischemia
    • Limb ischemia
      • Acute limb ischemia
        • Thrombectomies
        • Embolectomies
        • Anti-coagulation and Thrombolysis
      • Chronic limb ischemia
        • see intermittent claudication and peripheral artery occlusive disease
        • Diabetic foot ulcers
    • Mesenteric ischemia
    • Renal ischemia
  • Extracranial cerebrovascular disease
    • Carotid Endarterectomy and other carotid surgery
    • Surgery of the vertebral system
• Venous disease
  • Deep Vein Thrombosis
  • Thrombophlebitis
  • Varicose Veins and Varicosities
  • Venous malformations
• Lymphatic disease
  • Lymphoedema

• Vascular Medicine
  • Medical disorders with a significant vascular components, for example:
    • Raynaud's syndrome
    • Scleroderma

Training

Previously considered a field within general surgery, it is now considered a specialty in its own right. As a result, there are two pathways for training in the United States. Traditionally, a five year general surgery residency is followed by a 1-2 year (typically 2 years) vascular surgery fellowship. An alternative path is to perform a five or six year vascular surgery residency.

Programs of training are slightly different depending on the region of the world one is in.

Surgical procedures

By no means exhaustive, but below are a number of common procedures and indications for vascular surgeons.

Perioperative Guidelines in Vascular Surgery

Notes: Doses SHOULD BE CHECKED against approved local protocols.

Thromboprophylaxis.

- All patients: require below knee TED stockings, Deltaparin (2500 units sc) at 6 pm, and intermittent compression boots in theatre (if pulses exist). - All HIGH RISK patients requires Deltaparin 5000 units sc.

 * High risk patients include: Obese, history of DVT/PE, known thrombophilia, varicose veins, amputees, patients on HRT, bedbound for > 3days; surgery for cancer. 

Postcarotid endarterectomy hypertension - Patient in recovery:

 * Check pain status and missed antihypertensives. 
 * first line: Labetolol slow bolouses of 10 mg every two minutes up to 100 mg. 
 * second line (use for failed first line): Hydralazine 2 mg every 5 minutes up to 10 mg. 
 * third line: GTN infusion 5 ml/hr titrated to BP. Patient remain in level 2/3 care while on GTN infusion. 

- Patient in the Ward: [[BP > 170 mmHg + no Headache/neurologic symptoms]]

 * Patient NOT normally on antihypertensives: 
    - First line: Nifidipine 10 mg repeated after 1 hour if no change in BP. 
    - second line: Bisoprolol 5 mg
    - third line: Ramipril 5mg repeated in 3 hours if required. 
 * Patient IS normally on antihypertensives: 
    - First line: check existing medications. any missed dose? patient can not swallow (pass NGT). 
    - second line: use the ABCD protocol: 
      A = ACE inhibitors  B=Beta blockers  C=Calcium channel blockers  D=Diuretics
      If patient on A: add C
      If patient on C: add A
      If patient on D: add A
      If patient on A+C: add D
      If patient on A+D: add C
      If patient on A+C+D: add B

[[BP > 160 mmHg + Headache/neurologic symptoms]] Immediate action required. Apply non-invasive monitoring. Contact Consultant vascular surgeon in charge. Contact ITU SpR.

   - start 8 mg Dexamethazone IV.
   - First line: Labetolol: 10 mg slowly every 2 minutes up to 100 mg. 
   - Second line: Hydralazine: 2 mg slowly every 5 minutes up to 10 mg. 
   - Third line: GTN.

Major Trials in Vascular Surgery

- Edinburgh Artery Study. *Highwire results for Edinburgh Artery Study

- Netherland Vascular Study.²

- Framingham heart study. Highwire results for Framingham heart Study

- MASS Trial. – the Multicentre Aneurysm Screening Study (MASS) trial. Four centres (about 7000 men); screening (and treatment) vs. control group. AAA-related mortality in the screening arm reduced by about 40%; emergency ruptured AAA reducted by about 70%; disruption to elective work was reduced; and better management of risk factors and ITU/HDU beds. The overall survival benefits remain difficult to estimate, nevertheless, screening for AAA is recommended [level of recommendation: B].³⁴⁵

- UK Small Aneurysm Trial: 1090 patients; AAA 4-5.5 cm; Immediate surgery vs. ultrasound survillence (and treatement for rapid expansion or AAA >5.5); 30-day mortality after elective AAA repair is 5.8%. No difference in survival.⁶

- ADAM VA Cooperative Group Trial. 32697 patients screened; Age 50-79; AAA 4.0-5.4 cm; similar conclusion to Uk Small Aneurysm Trial.⁷

- Joint Vascular Resaerch Group Trial. 284 patients; Study the relationship between intraoperative intravenous heparinisation, blood loss during surgery and thrombotic complications. Conclusion: Intraoperative heparin, given before aortic cross clamping, is an important prophylaxic against perioperative MI in aortic aneurysm surgery.⁸

- HOPE (Heart Outcomes Prevention Evaluation) study - 4046 patients with PAD. In this subgroup, there was a 22% risk reduction in patients randomized to ramipril compared with placebo,which was independent of lowering of blood pressure.⁹

References

External links

• Society for Vascular Surgery (U.S.)
• European Journal of Vascular and Endovascular Surgery: the official journal of the European Society for Vascular Surgery.
• Division of Vascular Surgery and Endovascular Therapy at the Baylor College of Medicine

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