Vascular surgery is the medical subspecialty of surgery that deals with procedures on the human vascular system. It focuses in particular on narrowing of blood vessels (stenoses) and dilation of blood vessels (aneurysms). Surgical procedures—which are typically performed using endovascular techniques (via catheter-based interventions) but can also involve open surgery (by exposing the surgical site)—are often necessary on the abdominal aorta, the carotid arteries, and the leg arteries, among other sites.
Specialties closely related to vascular surgery include phlebology and cardiac surgery.
The standard method for treating vascular narrowing (stenosis) is to dilate the narrowed area using a catheter and a balloon (balloon catheter dilation, percutaneous transluminal angioplasty = PTA). To keep the blood vessel open in the long term, a stent may also be inserted. Since procedures during vascular surgery always carry an increased risk of clots breaking loose, the surgeon has the option of prophylactically implanting a small umbrella-like device downstream of the blood vessel.
A stent helps keep blocked or narrowed blood vessels open @ peterschreiber.media /AdobeStock
Another method of vascular surgery is embolectomy. In this procedure, the affected arteries in the groin or elbow are opened. A balloon catheter is then used to pull the clot out through the opened artery. A method similar to embolectomy is thrombendarterectomy. After making an incision in the skin, the artery is exposed, clamped off, and opened. The deposits (plaques) adhering to the inner wall of the vessel are scraped away. Clots that are still firmly attached to the vessel wall are also removed. The artery can then be closed again.
In vascular plasty, the artery is repaired on a larger scale after debridement. The additional vessel wall can be created from a strip of the patient’s own vein or from synthetic material.
If none of the aforementioned procedures can be performed, the narrowed or blocked vessel is bypassed. In most cases, a vein from the patient’s own leg is used for the “bypass.” Autologous material is not rejected and also causes less inflammation during the healing process. If the bypass surgery is successful, blood clotting is prevented by administering blood thinners such as aspirin or Marcumar®.
Blockages in the aortic segment near the heart are also caused by atherosclerosis in most cases. They are therefore particularly common in older adults.
As a result of an occlusion or narrowing, blood flow to the head is reduced, and the volume of blood pumped into the systemic circulation is decreased. This can lead to neurological deficits in the brain as well as a drop in blood pressure throughout the body. Vascular surgery in the aorta is intended to remove the narrowing and ensure unimpeded blood flow.
Mild cases of atherosclerosis in the aorta are treated with medication. Anticoagulants and blood pressure medications are the treatments of choice.
In severe cases, however, surgery is usually the only option. This vascular procedure is also known as stent-assisted angioplasty. During the procedure, the surgeon makes a small incision in the clavicular region to access the subclavian artery with a catheter. The catheter is advanced into the aorta, and an inflatable balloon (known as a stent) is deployed from within the catheter into the artery. This widens and clears the narrowed section.
Patients with multiple vessel occlusions or a long, extended occlusion may require open surgery, or the affected vessel may need to be bypassed during the procedure.
Acute peripheral arterial occlusion causes a sudden reduction in blood flow to an arm or leg, with the risk of the affected limb becoming gangrenous. In more than 85 percent of cases, the legs are affected.
Acute arterial occlusion is a medical emergency, as nerve tissue in the limb begins to die after just 2 hours of oxygen deprivation, and muscle tissue follows after about 6 hours. The main cause of arterial occlusion is a thrombosis or a dislodged clot (= embolus).
Swelling and a sensation of warmth at the affected site are signs of thrombosis @ hriana /AdobeStock
As a general emergency measure, heparin and other anticoagulants are administered to dissolve the occlusion with medication. If this is unsuccessful, vascular surgery must be performed. In this procedure, the classic approach involves removing the blockage using a catheter (= Fogarty catheter thrombectomy). The method works similarly to the vascular surgery performed for blockages in the aorta.
As people age, atherosclerosis in the blood vessels increases and does not spare the carotid arteries (arteria carotis), which supply the brain.
Plaque buildup and blood clot formation can lead to a reduced supply of blood and oxygen to the brain. Similarly, small clots can break off and cause an occlusion of the cerebral arteries, resulting in a stroke. Treatment options for carotid stenosis include open vascular surgery and vascular dilation using a balloon catheter (= stent).
Arterial occlusions in the lower leg are usually caused by atherosclerosis. If only one artery is affected, the patient usually does not notice any symptoms. Severe pain only occurs when an acute occlusion occurs, cutting off the blood supply to the lower leg.
For occlusions that can no longer be resolved with appropriate medication, a vascular procedure known as angioplasty (PTA) can be performed. In this procedure, a catheter is used to widen and clear the narrowed section of the vessel. Balloon catheters help keep the arteries in the lower leg open, even over the long term.
If the lower leg artery is damaged over a long stretch, it must be replaced with an autologous graft. For this, veins are harvested from the healthy leg and used as a vascular substitute. Bypasses can also be created to bypass the damaged section of the artery and remove it from the blood circulation.
Aneurysms are sac-like dilations of arteries, particularly the abdominal aorta, which can rupture due to overexertion or blunt trauma, leading to circulatory failure and hemorrhage within a very short time. Ruptured aneurysms are medical emergencies and require immediate vascular surgery.
There are essentially two procedures for treating aneurysms:
- Open vascular surgery and
- endovascular aneurysm repair.
In open surgery, the aneurysm is stabilized using a tubular prosthesis. First, an incision is made in the abdomen, and the abdominal aorta is then exposed. The dilated section of the vessel can be removed (resection). The aorta is reconstructed using a tubular plastic graft, which is inserted in place of the removed vascular segments.
In endovascular surgery, the prosthesis is inserted into the artery via a catheter. A blood vessel in the groin area is punctured, and a covered wire mesh (stent) is guided through the iliac artery into the dilated abdominal aorta. The stent is anchored so that blood can flow only through the stent. The dilated abdominal aorta itself is thereby isolated from the bloodstream.
This treatment is generally possible if there is no risk that vessels branching off from the abdominal aorta will be occluded by the stent. However, this vascular procedure is not an option for all patients, as its success depends on the degree of narrowing within the artery itself.
People with impaired kidney function or kidney failure must be prepared for dialysis (“blood cleansing”) at an early stage. This includes an examination of the vascular system to ensure that vascular access for hemodialysis can be established in a timely manner.
The wrist area is particularly well-suited for creating fistulas as vascular access. Here, the surgeon connects arteries and veins using a shunt (“bypass”), thereby enabling continuous blood withdrawal and return during dialysis.
For some patients with weak blood vessels or severe narrowing, vascular surgery—in which a prosthetic cylinder or catheter is inserted—can be helpful. Alternatively, fistulas for dialysis can also be created in the crook of the elbow or on the legs.
As a result of deep vein thrombosis in the leg that has been treated with medication, outflow obstruction or dysfunction of the venous valves in this area often occurs. This delays blood flow back to the heart, leading to high blood pressure in the venous system of the legs. The increased blood volume in the legs can promote the retention of fluid in the tissues (= edema formation).
Mechanical, pharmacological, and surgical methods are available for treating post-thrombotic syndrome.
Compression stockings have proven effective as a mechanical treatment; they exert gentle pressure on the veins, thereby reducing edema and supporting blood flow. Medication should be used to support this so-called compression therapy with agents that promote blood circulation and anticoagulants. Appropriate pain management can further improve quality of life.
It is important to note that contraceptives such as the “pill” can always increase the risk of thrombosis following a deep vein thrombosis in the leg. In the field of vascular surgery, the goal is to improve blood circulation.
Varicose veins and collateral circulation that lead to reflux or congestion are removed. In principle, it is possible to restore veins or venous valves through vascular surgery; however, this procedure is offered only at a very small number of specialized centers. The risk of recurrent thrombosis following vascular surgery is simply much higher than the potential benefit the procedure would provide to the patient.
Venous disorders usually start small and are almost imperceptible. However, they can quickly develop into more serious problems. That is why early detection of varicose veins is very important.
When detected early, treatment options are more diverse and vascular surgery is less invasive. For example, bulging veins (varicose veins) or blood clots can often be detected using ultrasound.
Starting with initial mild changes, the symptoms caused by varicose veins can worsen very quickly. Swelling and skin discoloration may occur and, for example, lead to an open leg ulcer. Early vascular surgery preserves healthy veins and keeps the surgical area small. Today, even larger varicose veins can be treated through very small incisions.
The surgical procedure of choice is the Babcock procedure. In this procedure, the trunk veins in the groin or behind the knee are separated from the deep vein and extracted using a special probe (Babcock probe). The side branches must be removed through many small incisions, which is not ideal from a cosmetic standpoint.
The method that is also cosmetically superior is vascular surgery using a cryoprobe. This probe is inserted into the trunk vein, and nitrous oxide is then released. The vein freezes to the probe and can be extracted from the subcutaneous fatty tissue along with it. This vascular procedure requires only a small incision in the groin, and even the larger side branches are removed simultaneously using the cryoprobe.
Newer procedures treat the saphenous vein using
- laser,
- radio waves,
- electrical current, or
- chemical substances
to sclerose the vessel. The sclerosed vein remains in the body.
Each procedure has its advantages and disadvantages. The extent to which this type of vascular surgery is superior to older methods must now be examined in studies.
Vascular injuries account for only a small portion of vascular surgery. Concealed vascular injuries with bleeding, which can result from trauma and accidents, are particularly problematic. In the legs, an undiagnosed vascular injury can even lead to amputation.
The goal of vascular surgery for vascular injuries is to repair the injury. For minor defects, the affected arteries or veins can be sutured after exposure. In cases of more extensive damage, the damaged vessel may need to be replaced with a vein graft taken from the patient’s own body.
Vascular infections are of particular significance in vascular surgery. It is not uncommon for them to result in amputation or the patient’s death. Very often, vascular surgery has preceded the actual infection. The causative pathogens are then usually hospital-acquired bacteria (= nosocomial infections).
Patients who have received a vascular prosthesis (e.g., a tubular prosthesis or balloon) are particularly at risk of infection.
In addition to systemic antibiotic treatment, repeat vascular surgery becomes increasingly important depending on the severity of the infection. On the one hand, the “infected” prosthesis can be removed and replaced with a different material. This is the recognized standard procedure in cases of infection following a vascular surgical procedure. However, the prognosis for these patients is not as good as it could be.
Alternatively, the body’s own tissue can be used to repair the defective area. Segments from the leg veins are most commonly used. While inflammatory reactions are somewhat reduced by the patient’s own tissue, the preoperative preparation and the subsequent harvesting procedure place a greater burden on the patient.
