Vascular surgery describes the medical branch of surgery that deals with interventions on the human vascular system. The focus here is on vascular constrictions (stenoses) and vascular dilatations (aneurysms). Surgical interventions, which are preferably interventional endovascular (using catheter interventions), but can also be performed using open surgery (by exposing the surgical area), are often necessary on the abdominal aorta, the carotid arteries and the leg arteries, among others.
Specialties closely related to vascular surgery are phlebology and cardiac surgery.
The standard method for vascular constrictions (stenoses) is to dilate the constriction using a catheter and a balloon(balloon catheter dilatation, percutaneous transluminal angioplasty = PTA). A stent can also be inserted to keep the blood vessel open in the long term. As interventions during vascular surgery always carry an increased risk of clots coming loose, the surgeon has the option of prophylactically inserting an umbrella in the downstream direction of the blood vessel.
A stent helps to keep blocked or narrowed blood vessels open @ peterschreiber.media /AdobeStock
Another method of vascular surgery is embolectomy. This involves opening the affected arteries in the groin or crook of the elbow. A balloon catheter is then used to pull the clot out through the opened artery. A similar method to embolectomy is thrombendarterectomy. After a skin incision, the artery is exposed, clamped and opened. The deposits (plaques) adhering to the inner wall of the vessel are scraped off. 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 scraping. The additional vessel wall can be made from a strip of the body's own vein or from plastic.
If none of the above-mentioned operations can be performed, the constricted or blocked vessel is bypassed. In most cases, an autologous vein from the leg is used for the "bypass". The body's own material is not rejected and also causes less inflammation during the healing process. If the bypass operation is successful, the blood is prevented from clotting by administering blood thinners such as Aspirin or Marcumar®.
In most cases, occlusions of the section of the aorta close to the heart are also caused by arteriosclerosis. They are therefore particularly common in older people.
As a result of an occlusion or narrowing, there is reduced blood flow in the area of the head and reduced ejection of blood into the systemic circulation. Symptoms of loss of circulation in the area of the brain and a drop in blood pressure in the body can occur. Vascular surgery in the area of the aorta is intended to dissolve the constriction and ensure unhindered blood flow.
Mild cases of arteriosclerosis in the area of the aorta are treated with medication. Anticoagulants and blood pressure medication are the drugs of choice.
In severe cases, however, surgery is usually the only option. This vascular operation is also known as stent-assisted angioplasty. The surgeon makes a small incision in the collarbone area in order to reach the subclavian artery with a catheter. The catheter is advanced into the aorta and an inflatable balloon (known as a stent) is inserted into the artery. This allows the constriction to be widened and exposed.
Patients who have multi-vessel occlusions or suffer from an elongated occlusion may have to undergo open surgery or the affected vessel may have to be bypassed during vascular surgery.
In acute peripheral arterial occlusion, there is a sudden reduction in blood flow to an arm or leg with the risk of the affected limb dying. In more than 85 percent of cases, the legs are affected.
Acute arterial occlusion is an emergency situation, as the nerve tissue in the limb dies after just 2 hours of oxygen deprivation, and the muscles also die after around 6 hours. The main cause of arterial occlusion is a thrombosis or a detached clot (= embolus).
Swelling and a feeling of warmth in the affected area are signs of thrombosis @ hriana /AdobeStock
As a general immediate measure, heparin and other anticoagulants are administered to dissolve the blockage with medication. If this is not successful, vascular surgery must be performed. The classic method is to dissolve the occlusion using a catheter (= catheter thrombolectomy according to Fogarthy). The method works in the same way as vascular surgery for occlusions in the aorta.
With advancing age, arteriosclerosis increases in the vessels and does not spare the carotidarteries as supply routes to the brain.
Deposits and clot formation can lead to a reduced supply of blood and oxygen to the brain. Small clots can also become detached and cause a blockage of the cerebral arteries, resulting in a stroke. Open vascular surgery and vasodilatation using a balloon catheter (= stent) are available for the treatment of carotid artery stenosis.
Arterial occlusions in the lower leg are usually caused by arteriosclerosis. If only one artery is affected, the patient is usually unaware of their condition. It is only when an acute occlusion occurs and the blood supply to the lower leg is cut off that severe pain occurs.
Vascular surgery, known as angioplasty (PTA), can be used for occlusions that can no longer be dissolved with suitable medication. This involves using a catheter to widen and clear the constriction in the vessel. Balloon catheters help to keep the arteries in the lower leg open in the long term.
If the lower leg artery is damaged over a longer distance, it must be replaced by an autograft. For this purpose, veins are harvested from the healthy leg and used as a vascular substitute. Bypasses can also be placed to remove the damaged part of the artery from the blood circulation.
Aneurysms are sac-like dilatations of arteries, especially the abdominal aorta, which can burst due to overstrain or blunt trauma and thus lead to circulatory failure and bleeding within a very short time. Ruptured aneurysms are emergencies and require immediate vascular surgery.
There are two main procedures for the treatment of aneurysms:
- Open vascular surgery and
- internal vascular removal (= endovascular aneurysm removal).
In an open operation, the aneurysm is stabilized using a tubular prosthesis. First, an abdominal incision is made 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 prosthesis, which is inserted in place of the removed vessel sections.
In vascular surgery, the prosthesis is inserted into the artery via a catheter. A blood vessel in the groin area is punctured and a coated wire mesh (stent) is inserted via the iliac artery into the dilated abdominal aorta. The stent is anchored so that the blood can only flow through the stent. The dilated abdominal aorta itself is thus removed from the blood flow.
This treatment is generally possible if there is no risk of the stent blocking vessels branching off from the abdominal aorta. However, this vascular operation is not available to all patients, as its success depends on the narrowing within the artery itself.
People with impaired kidney function or renal insufficiency must be prepared for dialysis ("blood washing") at an early stage. This also includes an examination of the vascular system in order to be able to create a vascular access for hemodialysis in good time.
The region around the wrist is particularly suitable for creating fistulas as a vascular access. Here, the surgeon connects arteries and veins using a shunt ("short circuit") and thus enables permanent blood collection and return during dialysis.
For some patients with weak vessels or severe constrictions, vascular surgery in which a prosthetic cylinder or catheter is inserted helps. Alternatively, fistulas for dialysis are also possible in the crook of the elbow or on the legs.
As a result of a deep vein thrombosis in the leg, which has been dissolved with medication, there is often an obstruction to the outflow or disruption of the venous valves in this area. This delays the outflow of blood towards the heart, which leads to high blood pressure in the venous system of the legs. The increased blood volume in the legs can promote the retention of water in the tissue (= edema formation).
There are mechanical, medicinal and surgical procedures for treating post-thrombotic syndrome.
Compression stockings have proven effective mechanically, exerting slight pressure on the veins and thus reducing oedema and supporting the drainage of blood. This so-called compression therapy can be supported with medication to promote blood circulation and anticoagulants. Adapted pain treatment can also improve the quality of life.
It is important to note that contraceptives such as the pill can always increase the risk of thrombosis after a deep vein thrombosis. In the field of vascular surgery, the aim is to improve blood circulation.
Varicose veins and bypass circulations that lead to pendulum blood flow or congestion are removed. The restoration of veins or venous valves is possible in principle through vascular surgery, but this operation is only offered in very few specialized centers. The risk of recurrent thrombosis after vascular surgery is simply much higher than the benefit that this operation would have for the patient.
Diseases of the veins usually begin small and almost imperceptibly. However, they can quickly develop into major problems. Early detection of varicose veins is therefore very important.
If detected early, the treatment options are even more varied and vascular surgery is less invasive. For example, bulging veins (varicose veins) or thromboses can often be detected using ultrasound.
Starting from the first slight changes, the symptoms of varicose veins can worsen very quickly. Swelling and skin discoloration can occur and end in an open leg, for example. Early vascular surgery protects healthy veins and keeps the area to be operated on small. Nowadays, even larger varicose veins can be treated through very small incisions.
The surgical procedure of choice is Babcock vascular surgery. The main veins in the groin or back of the knee are separated from the deep vein and pulled out using a special probe (Babcock probe). The side branches have to be pulled out via many small incisions, which is not ideal from a cosmetic point of view.
The cosmetically better method is vascular surgery using a cryoprobe. This probe is inserted into the main vein and then nitrous oxide is released. The vein freezes to the probe and can be pulled out of the subcutaneous fatty tissue with it. This vascular operation only requires a small incision in the groin and the larger side branches are also pulled together immediately with the cryoprobe.
Newer procedures treat the truncal vein using
- laser,
- radio waves,
- current applications or
- chemical substances
and obliterate the vessel. The obliterated vein remains in the body.
Each procedure has its advantages and disadvantages. The extent to which this type of vascular surgery is superior to the older methods must now be examined in studies.
Vascular injuries play only a minor role in vascular surgery. Hidden vascular injuries with bleeding, which can occur as a result of trauma and accidents, are particularly problematic. In the area of the legs, an unrecognized vascular injury can lead to amputation.
The aim of vascular surgery for vascular injuries is to repair the injury. Smaller defects can be sutured after exposing the affected arteries or veins. In the case of more extensive damage, the damaged vessel may have to be replaced with a vein graft from the patient's own body.
Vascular infections are of particular importance in vascular surgery. They often end in amputation or the death of the patient. Very often, vascular surgery precedes the actual infection. The germs causing the infection are then usually hospital germs (= nosocomial infections).
Patients who have received a prosthesis in the vascular area (e.g. tubular prosthesis, balloon) are particularly at risk of infection.
In addition to systemic antibiotic treatment, repeat vascular surgery becomes more important depending on the severity. On the one hand, the "infected" prosthesis can be removed and replaced with a different material. This is the recognized standard procedure in the case of infections following vascular surgery. However, the prognosis for the patients concerned is not as good as it could be.
On the other hand, autologous material can be used to repair the defect area. Sections from the leg veins are used most frequently. Although inflammatory reactions are somewhat reduced by the body's own material, the surgical preparation and the subsequent harvesting procedure are more stressful for the patient.
