Definition

A vascular surgeon is a physician trained in the care of the circulatory system. They are capable of performing both surgical and non-surgical treatment methods to a variety of conditions involving the circulatory system, except for conditions involving the brain or the heart. The word ‘vascular’ refers to the circulation of fluids in tubes. It comes from the Modern Latin word ‘vascularis’, an adjective that pertains to vessels or tubes, and the Latin ‘vasculum’, meaning ‘a small tube’.

Roles and Responsibilities

A vascular surgeon is trained to diagnose and treat conditions that relate to the arteries, veins, and lymphatic vessels in the whole body except the brain and the heart. Contrary to the name, a vascular surgeon does not necessarily treat all of the conditions relevant to their specialty with surgery. Advances in medical sciences and technologies have allowed for various methods of nonsurgical treatment, including simple lifestyle changes like diets and exercise, the insertion of tubes into the skin to ease the blood flow in blocked vessels, laser treatments, etc.

Vascular surgeons will often assess a patient’s entire vascular system to be able to look into the best course of treatment for the patient, with surgery as a last resort. Common conditions where vascular surgeons are needed include varicose veins, inflammations, and blood clots. Vascular surgeons are also sometimes involved in the care of patients with trauma injuries. Trauma injuries, like knife or bullet wounds, may cause inflammation or blocking of the blood vessels, which may cause more problems in time if not taken care of immediately by a vascular surgeon.

History

The earliest records of vascular surgery refer to various methods of the control of bleeding. The use of various styptics, which are materials that stop bleeding when applied to a wound, appear in many points in history. Ancient Egyptians create styptics from lead sulfate, copper sulfate and antimony. This practice is dated from around 1600 BCE and described in the Ebers Papyrus. Copper sulfate was also a popular styptic in Europe during the Middle Ages. In Ancient India, hot oils, compression, elevation and cold were used to control bleeding. The Chinese used tight bandaging and styptics around 1000 BCE.

In De Medicina, Roman encyclopedist Celsus introduces ligature as a way to control bleeding in surgical operations to treat multiple types of hernia in 25 CE. Celsus also describes the necessary pre- and post-operative care needed for hernia patients. A hernia is the entering of organs or fatty tissue into weak areas in surrounding tissue or connecting tissue. Some of the terminologies and methods detailed in De Medicina are still in use today. Patients in his time were operated on lying down facing upwards. As a pre-operative measure, patients in his time were asked to fast and drink plenty of fluids for three days. This is still being done today for operations on intestinal hernia. Most importantly, hernia operations introduce severe bleeding. Celsus used ligature techniques to control bleeding, and he would have injured vessels tied in place with lint threads. After this, the vessel would then be cut in between.

Aside from having an extensive knowledge of vascular anatomy, Rufus of Ephesus also noted that a partially severed artery would continue to bleed, but a completely severed artery would close and stop bleeding in a short period of time. Galen, a Roman physician, differentiated the rate of bleeding and responses required between bleeding from arteries and veins. He recommended the application of pressure on surface vessel bleeding to allow blood to clot, thus stopping bleeding. For deeper vessel injuries, the response depended on the source of the bleeding. If bleeding comes from a vein, and therefore much less severe, pressure and styptics would suffice. If bleeding comes from an artery, ligation was recommended.

The next advancement comes from the Middle Ages in Europe. At the time, war was commonplace and many soldiers needed care from gunshot wounds. Guns and bullets often caused severe soft tissue damage and bone fractures, along with the likelihood of infection and contamination from the bullet and the patient’s clothing. These would often cause tissue death, or gangrene, due to blood loss. The only response to such injuries at the time was amputation. At the time, amputations were performed directly on the site of gangrene and cauterization was performed to seal the wound and control the putrefaction caused by gangrene. Cauterization would also burn off parts of the skin needed to seal the site of amputation, which further increased the risk of infection.

Military surgeon Ambroise Paré was one of the first to suggest amputation above the areas affected by gangrene and ligation to control bleeding. During his service, he discovered that cauterization by hot oil, which was used at the time because physicians believed that gunpowder poisoned bullets and hot oil is the only way to control this poison, was not as effective as his concoction of egg yolk, rose oil and turpentine, which he made because he ran out of hot oil. While those who were given the hot oil were feverish and had swelling and pain on their wounds, those who were given his mixture slept well with little swelling. A few years after, he would operate on a soldier whose leg was crushed by a cannon shot. Instead of cauterizing after the amputation, he used ligation to control the bleeding. The soldier would return happily with a wooden leg, happy to not have been burned.

The first record of a successful direct repair of a damaged artery is in 1759, where Hallowell, upon the advice of Lambert, placed a pin through the walls of the artery and applying a suture shaped like a figure-8 around the pin. This is known as the farrier’s stitch. This result could not be replicated for a very long time, likely due to the lack of anesthesia at the time and the risk of infection. The next successful direct repair operation on a damaged artery would be by Broca in 1762, followed by Postemski in 1886.

Surgical repair methods continued to improve in time due to experimentation and developments in anesthesia and infection control. In 1896, J.B. Murphy performed the first successful end-to-end anastomosis on a person. He had previously been trying to experimentally determine the maximum amount of vessel that can be removed while still safely connecting the two ends. The operation was done by removing the damaged area of the artery. The open ends of the artery would then be stretched and overlapped onto each other. The, afterwards, the overlaps would be sutured. The person’s circulation showed no abnormalities three months after the procedure.

Times of war introduced several difficulties to vascular surgery. During World War 1 and World War 2, high velocity bullets and explosives were introduced, which made traditional techniques less effective. The amount of time between wounding and treatment also made treatment difficult. Ligation and amputation was the treatment of choice at the time, even though it was already known that the procedures had risks associated to them, like secondary bleeding and nerve damage. The wars thereafter introduced rapid evacuation by air, which significantly improved soldiers’ chances for treatment. Direct artery repair instances increased and amputation rates decreased. Better strategies, both surgical and non-surgical, continued to be developed at this time.

Common Conditions and Treatment Methods

Atherosclerosis

Atherosclerosis is characterized by the hardening and narrowing of blood vessels. Materials like fat, cholesterol, calcium and others may cause further problems, including stroke, heart attacks, amputation and even death. It is one of the leading causes of death in the United States for both men and women. However, no symptoms appear until the build-up’s later stages. When sufficient build-up sufficiently reduces blood flow, pain may be felt in the immediate area. If the build-up is close to the heart, a heart attack may occur. If the build-up is close to the neck, a stroke may occur. There are many risk factors associated with atherosclerosis. A family history of the illness is a significant risk factor, along with lifestyle choices such as smoking, high cholesterol or sugar intake and lack of physical activity. Stress, mental health issues, high blood pressure and inflammation are also risk factors for atherosclerosis. Prevention is generally the key to combating atherosclerosis. Maintaining a healthy diet along with physical activity reduces the risks of atherosclerosis.

When detected early, a vascular surgeon may recommend lifestyle changes to reduce the risks of atherosclerosis. For people with high cholesterol, high blood pressure or high blood sugar, medication may be prescribed. For more severe case, an angioplasty may be needed. A small incision is made in the arm or groin area. A catheter is inserted into the incision which carries a stent with a small balloon to the area with the build-up. Once the stent is in position, the small balloon is inflated which expands the stent, locking it in place within the vessel. The balloon is then deflated and removed along with the catheter. Due to its minimally invasive nature, only local or regional anesthesia is needed. Recovery time for this procedure is usually a few hours. As a last resort, a vascular surgeon may perform a surgical bypass. A synthetic or natural graft is surgically placed in the blood vessels that will divert blood flow from blocked areas. This operation is associated with many risks. The graft may become blocked after some time, at which point another surgery would be required. Infections also become more likely. The operation is also associated with significant pain, sometimes requiring rehabilitation. The recovery time is significant for this operation, reaching up to a few weeks, possibly with multiple follow up visits to the vascular surgeon.

Aortic Aneurysms

When an area of a blood vessel is weakened, the normal flow of blood may cause the weakened area to stretch and bulge, leading to an aneurysms. Aneurysms commonly form in the aorta, a major artery in the heart and the largest artery in the body. Aneurysms of this type may rupture, causing severe, life threatening bleeding. Aneurysms may be caused by smoking, high blood pressure, infection, trauma, or heredity. People above the age of 65 have a heightened risk of developing an aneurysm. The most common symptom of an aortic aneurysm is chest pain. Depending on the location of the aneurysm, different symptoms may present themselves. Aneurysms close to the chest cause continuous coughs. Aneurysms close to the abdomen may cause gastrointestinal bleeding. When ruptured, aneurysms may cause sudden back pain, dizziness, weakness, seating and rapid heartbeat. Since aortic aneurysms do not usually present symptoms until very late in its development, people who are at risk of an aneurysm, such as people above the age of 65 and/or have a family history of aneurysms, should have themselves tested. An aneurysms can also be detected during routine medical examinations.

There are many treatment methods for aneurysms depending on its size and severity. When an aortic aneurysm close to the abdomen is more than 5 centimeters, surgical repair is needed. A tube called a graft made of synthetic material is surgically placed in the weakened areas of the vessel which facilitate normal blood flow. The procedure is known to be safe, and recovery time is known to be about a week. When open surgery is too risky, vascular surgeons may perform an angioplasty through the groin instead.

Carotid Artery Disease

There are two major arteries on both sides of the throat, and these arteries, called carotid arteries, send blood to the brain. Over time, these arteries may narrow or become blocked. Blood flow to the brain is reduced, which may cause a Transient Ischemic Attack(TIA), something similar to a stroke. A TIA is generally characterized by the same symptoms as a stroke, including numbness of the limbs, drooping of the face, confusion, memory loss, headaches, difficulty in seeing, speaking and understanding speech. A TIA lasts for minutes to hours, while strokes last for more than a day. A blockage in the carotid artery presents no symptoms, but may put a person at risk of a stroke. The causes of Carotid Artery Disease remains unknown, but people who smoke, have high cholesterol, high blood pressure, diabetes, or obesity are at a significant risk. People who have a family history of the disease may also be at risk of having the disease.

Mild versions of the disease can be treated with medication and lifestyle changes, such as diets and not smoking. Severe versions of the disease may be treated with a Carotid Endarectomy. An incision is done to the side of the neck to expose the artery. Clamps are used to stop blood flow to the affected area. In some cases, a shunt may be inserted in the artery to divert blood flow. The artery itself is then opened and a device is used to remove plaque buildup from the artery. Once done, the artery is sealed and the shunt is removed. When open surgery is a risk, an angioplasty may also be an option. A stent is inserted into the carotid artery to aid in blood flow. The process is the same as when a stent is inserted in the aorta, except the catheter has to travel from the groin to the carotid. This procedure’s long term effects have not been sufficiently tested and studied. Only people who elect to join a clinical trial or those who are not allowed to have a carotid endarectomy are allowed to have this procedure.

Fibromuscular Dysplasia

Fibromuscular Dysplasia(FMD) causes arteries in the body to narrow due to abnormal cell development. This narrowing may lead to aneurysms or tearing. FMD frequently affects the kidneys and the carotid arteries, with rare cases in the leg and intestinal arteries. Its causes and risk factors are unknown, but it has been commonly found in many young women from Europe. People with FMD commonly have high blood pressure. If FMD occurs near the carotid arteries, headaches and neck pain may occur, along with a “whooshing” sound in the ear called pulsatile tinnitus. In severe cases, TIA may occur. When FMD occurs in the legs, pain may be experienced while walking. When in the intestinal arteries, pain occurs while eating.

Treatment for FMD is a daily aspirin, which control the narrowing of the arteries. An angioplasty may also be performed on relevant vessels when needed. Surgery is rarely required. There is no known way of preventing FMD, but people who have FMD can generally live normally with daily aspirin and a healthy lifestyle.

Varicose Veins

Veins are vessels that return blood to the heart. In the legs, this process is done against gravity. To aid in blood flow, veins have valves that both prevent blood from flowing backward and aid blood in flowing forward while walking. When the valves do not function correctly, blood may begin to pool in the veins and cause varicose veins. Burning, itching, swelling, and pain may be felt. Leg heaviness and tiredness may also be experienced. Symptoms worsen throughout the day and may be alleviated partially by elevation or socks or stockings that compress the legs. Phlebitis, a condition where varicose veins become hot, hard, discolored and burning, may also occur. Phlebitis is temporary, with symptoms going away in months. Varicose veins are also sensitive to trauma. Even minor trauma may cause varicose veins to burst and bleed. In severe cases, the skin around the veins may tear.

Compression socks are often recommended for symptom management of varicose veins. These socks are knee-high and provide pressure that increases towards the foot. These socks help prevent blood from pooling in the veins by compressing the veins. If compression socks do not provide enough relief, ablation therapy may be performed, provided that the veins affected are sufficiently straight. Anesthetics will be introduced to the area by injection and catheter through the veins. Once the entire area is numb, an ablation catheter is passed through the vein to treat it.

Ablation may be done through laser or radiofrequency. Both will cauterize the vein. This operation is painless due to anesthesia with rare instances of complications. Among these rare complications is nerve damage and skin burns. If veins are not straight enough, sclerotherapy may be done instead. The leg is first elevated to drain blood. A chemical called a sclerosant is then injected into the target veins. This chemical causes the vein to clot, which would then close the vein. This clot is not dangerous and is broken down by the body’s natural processes. Once the process is done, compression stockings will be required to prevent blood from returning to the veins temporarily. Multiple injections and multiple treatment repetitions may be necessary depending on the nature and number of varicose veins. The injection itself may be painful and may cause cramping in the immediate area.

Vascular Trauma

Accidents, automobile injuries and wounds from blunt weapons, sharp weapons and guns are very common sources of injury to the blood vessels. Vascular trauma is categorized by injury type. Blunt injuries for when a blood vessel is crushed or stretched and penetrating injuries for when vessels are punctured, severed or torn. Both types can cause clots to form, which reduce blood flow to vital organs. Both types can also cause bleeding which leads to other potentially life-threatening conditions.

Treatment for vascular trauma may require a surgical bypass. As with the case in atherosclerosis, a natural or synthetic graft is attached to allow blood to detour from damaged areas of a vessel, usually an artery. In the case of veins, ligation may be sufficient. Angioplasty may also be performed for collapsed vessels. A stent graft may also be done during the angioplasty if needed to keep the vessels open. When muscle damage is involved, a fasciotomy may be required. Muscles tend to swell when damaged, further obstructing blood flow. The fascia, which is the layer of connective tissue under the skin that separates the muscles from the skin, must be cut open to allow the muscles to swell unobstructed, leaving the blood vessels safe to treat. The skin is left open while the vessels are being treated, sometimes for multiple days. Sometimes, a skin graft is necessary for wounds that are severe or in prolonged exposure. The skin graft aids in the recovery of the wound. 

References

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Landry, G. J. (n.d.). Fibromuscular Disease. Retrieved from https://vascular.org/patient-resources/vascular-conditions/fibromuscular-disease

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Sclerotherapy for Varicose Veins. (n.d.). Retrieved from https://www.webmd.com/skin-problems-and-treatments/sclerotherapy-for-varicose-veins

What is a Vascular Surgeon? (n.d.). Retrieved from https://vascular.org/patient-resources/what-vascular-surgeon

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