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VASCULAR SURGERY
BACKGROUND
INTRODUCTION: Vascular surgery, also known as peripheral vascular
surgery, refers to operations on the arteries and veins of the body
except for the coronary and brain arteries. Most vascular operations
involve the arteries, though veins require operations as well.
The causes of arterial diseases or problems are wide-ranging, but
most vascular disease results from atherosclerosis. Other causes of
surgical problems of the arteries include congenital malformation,
trauma, and rare acquired diseases of the arteries.
ATHEROSCLEROSIS: Also known as arteriosclerosis, atherosclerosis is
the most common disease affecting the arteries. People used to refer
to atherosclerosis as hardening of the arteries. Atherosclerosis can
be very mild, leading to no symptoms, or it can be severe, leading
to life or limb threatening complications. An artery affected by
atherosclerosis will have deposition of cholesterol plaque and
calcium in the wall of the artery. This plaque can severely narrow
or occlude an artery and thus limit or stop blood flow through the
artery. Alternatively, pieces of the plaque may break off and
embolize, which means that the pieces flow through the artery and
then lodge in a smaller branch of the artery, often leading to
adverse consequences.
Atherosclerosis is caused or made worse by a number of environmental
factors. Smoking is the most important of theses factors. Without
doubt smoking greatly worsens atherosclerosis in many (probably
most) smokers. Stopping smoking is critical in any plan (surgical or
otherwise to control this disease. Diets high in saturated fats,
trans-fats, and total calories will often worsen atherosclerosis.
People who are genetically predisposed to vascular problems, like
stroke and heart attack, must be very careful to avoid smoking and
unwise eating habits. Your primary care physician can help with
smoking cessation and appropriate diet plans.
Diabetes also contributes to atherosclerosis. Essentially all
vascular problems are more common in diabetic people. Excellent
control of blood sugars can help prevent these problems. Many
diabetic people require vascular operations. Surgical outcomes in
diabetic patients are similar to outcomes on non diabetic patients.
The most common vascular problems that we manage as surgeons include
carotid artery disease, lower extremity vascular insufficiency,
aortic aneurysms, and aneurysms of other arteries. Additionally
renal artery disease and mesenteric artery disease (poor blood flow
to the intestines) are often managed surgically. The most common
venous problems managed operatively or conservatively are varicose
veins and lower extremity venous insufficiency. Following are
descriptions of some of these problems and their management.
Carotid Artery Disease - The carotid arteries are the major arteries
on each side of the neck that carry blood to the brain.
Atherosclerosis will often lead to plaque formation in the carotid
arteries, leading to partial of complete occlusion of the vessels.
Additionally, pieces of plaque can break off and embolize to the
brain, leading to a stroke. If a piece of plaque is very small, the
"stroke" may be temporary, a condition called a transient ischemic
attack, or TIA.
Evaluation of the carotid arteries is usually done in a vascular
laboratory using ultrasound and Doppler technology. Plaque can be
detected and the degree of stenosis (narrowing) can be estimated.
Sometimes and arteriogram is needed to evaluate the carotid
arteries. Arteriograms are done at a hospital, usually as an
outpatient, and consist of contrast material being injected into the
arteries while x-rays films are being taken. Arteriograms provide
the most precise information about the arteries.
The most common operation on the carotid arteries is called carotid
endarterectomy. The operation starts with an approximately 3-4 inch
incision on the neck over the artery. The carotid artery is opened,
the plaque is carefully removed, and the artery is closed. Most
patients spend one night in the intensive care unit and then either
go home or spend one more night in the hospital. Generally, most
daily activities can be resumed upon discharge from the hospital,
although driving and return to work are usually delayed for 5-7
days.
The reason for doing carotid endarterectomy is to prevent a stroke.
In some patients, a TIA has served as a warning of impending stroke.
Other patients are found to have severe narrowing of one or both
carotid arteries by vascular lab testing. Both TIA and severe
narrowing (stenosis) of the artery are known to markedly increase
the rick of stroke. Some patients do not have a TIA before a stroke.
Complications, through unusual, can occur with carotid
endarterectomy. The complications can include stroke, heart attack,
bleeding, or even death. Since these complications can be severe,
carotid endarterectomy is reserved for patients considered at
acceptable risk for surgery and with severe carotid disease placing
the patient at high risk of complications without surgery.
Lower Extremity Vascular Insufficiency - The arteries carrying blood
to the lower extremities include the aorta and many arteries in the
pelvis and legs. Atherosclerosis is the usual cause of narrowing or
occlusion of the arteries supplying the legs with blood. The problem
may be at a single level, such as the aorta, or it may involve
several different arteries. With lower extremity vascular
insufficiency, a person may experience claudication. Claudication is
the uncomfortable of painful sensation in the muscles of the lower
legs (or upper leg) with walking. The discomfort resolves with rest.
More severe disease will lead to pain in the foot, even at rest.
Some patients will develop sores on the feet with or without pain.
Physical examination and vascular lab testing are usually used to
evaluate the problem. In situations where intervention is being
considered, and arteriogram is usually ordered. The arteriogram will
localize the site of the stenoses (narrowed areas) and occlusions.
Management of the problem may be medical (exercise and medications),
"minimally invasive" (angioplasty), or operative.
Angioplasty is most commonly done by dilating a narrowed artery
segment with a special balloon on a catheter. This requires a
puncture of an artery at the groin (femoral artery) but no incision.
If the problem in the artery is well localized, and not completely
occlusive, angioplasty is often a good option.
Operative intervention usually involves a bypass procedure. The
bypass may be from the aorta to the femoral arteries (major arteries
in the groins). Alternatively, the bypass may be from a femoral
artery to the knee, ankle or foot level. These operations are often
referred to as "fem-pop bypass" or "fem-tib bypass" procedures
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