Vascular surgery

From Wikipedia, the free encyclopedia
  (Redirected from Vascular surgeon)
Jump to navigation Jump to search

Vascular surgery
SurgicalAAA 01 Base 275.jpg
NamesDoctor, Medical Specialist, Surgeon
Occupation type
Activity sectors
Education required
Fields of
Hospitals, Clinics

Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or arteries, veins and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The specialty evolved from general and cardiac surgery, and includes treatment of the body's other major and essential veins and arteries. Open surgery techniques, as well as endovascular techniques are used to treat vascular diseases. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature.


Early leaders of the field included Russian surgeon Nikolai Korotkov, noted for developing early surgical techniques, American interventional radiologist Charles Theodore Dotter who is credited with inventing minimally invasive angioplasty (1964), and Australian Robert Paton, who helped the field achieve recognition as a specialty. Edwin Wylie of San Francisco was one of the early American pioneers who developed and fostered advanced training in vascular surgery and pushed for its recognition as a specialty in the United States in the 1970s.


Medical science has advanced significantly since 1507, when Leonardo da Vinci drew this diagram of the internal organs and vascular systems of a woman.

The specialty continues to be based on operative arterial and venous surgery but since the early 1990s has evolved greatly. There is now considerable emphasis on minimally invasive alternatives to surgery. The field was originally pioneered by interventional radiologists, chiefly Dr. Charles Dotter, who invented angioplasty. Of note, Dr. Thomas Fogarty invented the balloon catheter which enabled angioplasty. Further development of the field has occurred via joint efforts between interventional radiology, vascular surgery, and interventional cardiology. This area of vascular surgery is called Endovascular Surgery or Interventional Vascular Radiology, a term that some in the specialty append to their primary qualification as Vascular Surgeon. Endovascular and endovenous procedures (e.g., EVAR) can now form the bulk of a vascular surgeon's practice.

The treatment of the aorta, the body's largest artery, dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century AD. Modern treatment of aortic diseases stems from development and advancements from Michael DeBakey and Denton Cooley. In 1955, DeBakey and Cooley performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the Dacron graft, resulting in a revolution for surgeons in the repair of aortic aneurysms. He also was first to perform cardiopulmonary bypass to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery. Dr. Edward "Ted" Dietrich, one of Dr. DeBakey's associates, went on to pioneer many of the minimally invasive techniques that later became hallmarks of endovascular surgery. [1] Dietrich later founded the Arizona Heart Hospital in 1998 and served as its Medical Director from 1998 to 2010. In 2000, Diethrich performed the first endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm. Dietrich trained several future leaders in the field of endovascular surgery at the Arizona Heart Hospital including Venkatesh Ramaiah, MD[2] who served as medical director of the institution following Dietrich's death in 2017.[3]

The development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in general surgery. Most vascular surgeons would now confine their practice to vascular surgery and similarly, general surgeons would not be trained or practice the larger vascular surgery operations or most endovascular procedures. More recently, professional vascular surgery societies and their training program have formally separated "Vascular Surgery" into a separate specialty with its own training program, meetings, accreditation. Notable societies are Society for Vascular Surgery (SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZSVS). Local societies also exist e.g. New South Wales Vascular and Melbourne Vascular Surgical Association (MVSA). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella e.g. Royal Australasian College of Surgeons (RACS).


Arterial and venous disease treatment by angiography, stenting, and non-operative varicose vein treatment sclerotherapy, endovenous laser treatment are rapidly replacing major surgery in many first world countries. These newer procedures provide reasonable outcomes that are comparable to surgery with the advantage of short hospital stay (day or overnight for most cases) with lower morbidity and mortality rates. Historically performed by interventional radiologists, vascular surgeons have become increasingly proficient with endovascular methods.[4] The durability of endovascular arterial procedures is generally good, especially when viewed in the context of their common clinical usage i.e. arterial disease occurring in elderly patients and usually associated with concurrent significant patient comorbidities especially ischemic heart disease. The cost savings from shorter hospital stays and less morbidity are considerable but are somewhat balanced by the high cost of imaging equipment, construction and staffing of dedicated procedural suites, and of the implant devices themselves. The benefits for younger patients and in venous disease are less persuasive but there are strong trends towards nonoperative treatment options driven by patient preference, health insurance company costs, trial demonstrating comparable efficacy at least in the medium term.

A recent trend in the United States is the stand-alone day angiography facility associated with a private vascular surgery clinic, thus allowing treatment of most arterial endovascular cases conveniently and possibly with lesser overall community cost. Similar non-hospital treatment facilities for non-operative vein treatment have existed for some years and are now widespread in many countries.

NHS England conducted a review of all 70 vascular surgery sites across England in 2018 as part of its Getting It Right First Time programme. The review specified that vascular hubs should perform at least 60 abdominal aortic aneurysm procedures and 40 carotid endarterectomies a year. 12 trusts missed both targets and many more missed one of them. A programme of concentrating vascular surgery in fewer centres is proceeding.[5]


Vascular surgery
OPS-301 code5-38...5-39

Vascular surgery encompasses surgery of the aorta, carotid arteries, and lower extremities, including the iliac, femoral, and tibial arteries. Vascular surgery also involves surgery of veins, for conditions such as May–Thurner syndrome and for varicose veins. In some regions, vascular surgery also includes dialysis access surgery and transplant surgery.

It is unclear on the benefits and harms of wound drainage after lower limb arterial surgery.[6]

The main disease categories and procedures associated with them are listed below.

Indication/disease Procedure
Acute limb ischaemia Balloon embolectomy


Vascular bypass grafting


Abdominal aortic aneurysm (AAA) Open aortic surgery

Endovascular Aneurysm Repair (EVAR)

Aortic dissection Open aortic surgery

Thoracic Endovascular Aneurysm Repair (TEVAR)

Aortoiliac occlusive disease angioplasty

vascular bypass

Atherosclerosis angioplasty

vascular bypass

Buerger's medical



IV PGI by pass

Carotid stenosis Carotid endarterectomy

Carotid stenting

Chronic kidney disease Cimino fistula

Dialysis catheter placement

Chronic venous insufficiency Endovenous laser treatment

Vein stripping

Connective tissue disease Genetically triggered Aortic dissections
Deep vein thrombosis Inferior vena cava filter


Fibromuscular dysplasia angioplasty
Giant-cell arteritis
Lymphedema Vascularized lymph node transfer

Lymphaticovenous anastomosis

Suction assisted lipectomy

Low level laser therapy

Median arcuate ligament syndrome Surgical median arcuate ligament release
Mesenteric ischemia Surgical revascularization
Peripheral arterial occlusive disease Angioplasty with/out Stenting

Vascular bypass



Popliteal artery entrapment syndrome
Portal hypertension Portosystemic shunt
Pseudoaneurysm Covered stent

Surgical ligation with or without vascular bypass

Pulmonary embolism Inferior vena cava filter

Suction thrombectomy

Renovascular hypertension Surgical revascularization
Stroke and Transient ischemic attack Carotid endarterectomy
Subclavian steal syndrome Medical management

Carotid-subclavian bypass

Angioplasty and stenting

Thoracic aortic aneurysm Hybrid arch debranching

Thoracic endovascular aneurysm repair

Thoracic outlet syndrome Surgical decompression
Varicose veins Vein stripping


Endovenous Laser Treatment

Ambulatory phlebectomy

Vascular access steal syndrome Angiography

Distal Revascularization and Interval Ligation (DRIL)

Revision using distal inflow

MILLER banding

vascular access complications open surgery



Major trials[edit]

  • Netherland Vascular Study[7]
  • MASS Trial – The Multicentre Aneurysm Screening Study (MASS) trial, which found reduced mortality after screening for abdominal aortic aneurysms in the UK.[8]
  • UK Small Aneurysm Trial – 1090 patients; AAA 4-5.5 cm; Immediate surgery vs. ultrasound surveillance (and treatment for rapid expansion or AAA >5.5); 30-day mortality after elective AAA repair is 5.8%. No difference in survival.[9]
  • ADAM VA Cooperative Group Trial – 73451 VA patients screened with no known hx of aneurysm; Age 50-79; AAA 4.0-5.4 cm; similar conclusion to Uk Small Aneurysm Trial.[10]
  • Joint Vascular Research Group Trial – 284 patients; Study the relationship between intraoperative intravenous heparinization, blood loss during surgery and thrombotic complications. Conclusion: Intraoperative heparin, given before aortic cross clamping, is an important prophylactic against perioperative MI in aortic aneurysm surgery.[11]
  • North American Symptomatic Carotid Endarterectomy Trial (NASCET) 1415 patients; trial that showed carotid endarterectomy was beneficial in symptomatic patients. Two year stroke rate in patients with > 70% carotid stenosis decreased from 26% to 9%. Two year stroke rate in patients with > 50% decreased from 15% to 9%.[12][13]
  • Asymptomatic Carotid Atherosclerosis Study (ACAS) 1662 patients; demonstrated benefit in asymptomatic patients with >60% stenosis. Fiver year stroke rate reduced from 11% to 5.1% with carotid endarterectomy.[14][15]


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. In many countries, Vascular surgeons can opt into doing additional training in cardiac surgery as well as post-residency.

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

Country Standards body Professional representation Minimum Length of training (post intern)
Australia and New Zealand Royal Australasian College of Surgeons Australian & New Zealand Society of Vascular Surgery (ANZSVS) 6 years
Canada Royal College of Surgeons of Canada Canadian Society for Vascular Surgery 5 years
United Kingdom Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh Vascular Society of Great Britain and Ireland 8 years
United States American Board of Surgery, American Osteopathic Board of Surgery Society for Vascular Surgery

American College of Surgeons

5 years ( 4 via 5-year integrated Vascular Surgery Residency). 7 if completing as a 2 year fellowship following general surgery[16]
Italy 5 years
Iran Iran National Board of Vascular Surgery Iranian College of Vascular Surgeons 7 years ( 4 years of general surgery + 3 years of vascular surgery)

See also[edit]


  1. ^ Coselli, Joseph S.; Preventza, Ourania (2017-06-01). "In Memoriam: Edward B. Diethrich, MD (1935–2017)". Texas Heart Institute Journal. 44 (3): 164–166. doi:10.14503/THIJ-17-6354. ISSN 0730-2347. PMC 5505391.
  2. ^ Dr. Venkatesh Ramaiah: "Dr. Ted Diethrich lessons carried forward" - The Antegrade Flow Show, retrieved 2021-10-28
  3. ^ "Dr. Ted Diethrich, founder of Arizona Heart Institute, dies at 81". Retrieved 2021-10-28.
  4. ^ Suckow BD, Goodney PP, Columbo JA, Kang R, Stone DH, Sedrakyan A, Cronenwett JL, Fillinger MF (Jun 2018). "National Trends in Open Surgical, Endovascular and Branched/Fenestrated Endovascular Aortic Aneurysm Repair in Medicare Patients". Journal of Vascular Surgery. 67 (6): 1690–1697.e1. doi:10.1016/j.jvs.2017.09.046. PMC 5970963. PMID 29290495. Retrieved 23 Sep 2020.
  5. ^ "Trusts reveal plans to centralise services after GIRFT review". Health Service Journal. 19 March 2018. Retrieved 13 May 2018.
  6. ^ Healy, Donagh; Clarke-Moloney, Mary; Hannigan, Ailish; Walsh, Stewart (2016-11-11). Cochrane Wounds Group (ed.). "Wound drainage for lower limb arterial surgery". Cochrane Database of Systematic Reviews. 2016 (11): CD011111. doi:10.1002/14651858.CD011111.pub2. PMC 6465115. PMID 27841438.
  7. ^ Hooi JD; Kester AD; Stoffers HE; Overdijk MM; van Ree JW; Knottnerus JA (April 2001). "Incidence of and risk factors for asymptomatic peripheral arterial occlusive disease: a longitudinal study". Am J Epidemiol. 153 (7): 666–72. doi:10.1093/aje/153.7.666. PMID 11282794.
  8. ^ Ashton HA; Buxton MJ; Day NE; et al. (November 2002). "The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial". Lancet. 360 (9345): 1531–9. doi:10.1016/S0140-6736(02)11522-4. PMID 12443589. S2CID 21497118.
  9. ^ "Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants". Lancet. 352 (9141): 1649–55. November 1998. doi:10.1016/S0140-6736(98)10137-X. PMID 9853436. S2CID 24733279.
  10. ^ Lederle FA; Wilson SE; Johnson GR; et al. (August 1994). "Design of the abdominal aortic Aneurysm Detection and Management Study. ADAM VA Cooperative Study Group". J Vasc Surg. 20 (2): 296–303. doi:10.1016/0741-5214(94)90019-1. PMID 8040955.
  11. ^ Thompson JF; Mullee MA; Bell PR; et al. (July 1996). "Intraoperative heparinisation, blood loss and myocardial infarction during aortic aneurysm surgery: a Joint Vascular Research Group study". Eur J Vasc Endovasc Surg. 12 (1): 86–90. doi:10.1016/S1078-5884(96)80281-4. PMID 8696904.
  12. ^ Barnett, Henry J.M.; Taylor, D. Wayne; Eliasziw, Michael; Fox, Allan J.; Ferguson, Gary G.; Haynes, R. Brian; Rankin, Richard N.; Clagett, G. Patrick; Hachinski, Vladimir C.; Sackett, David L.; Thorpe, Kevin E. (1998-11-12). "Benefit of Carotid Endarterectomy in Patients with Symptomatic Moderate or Severe Stenosis". New England Journal of Medicine. 339 (20): 1415–1425. doi:10.1056/NEJM199811123392002. ISSN 0028-4793. PMID 9811916.
  13. ^ LLC, Peripheral Brain. "NASCET - Wiki Journal Club". Retrieved 2021-02-11.
  14. ^ "Table 1: The Single Nucleotide Polymorphisms in cathepsin B protein mined from literature (PMID: 16492714)". doi:10.7717/peerj.7425/table-1. Cite journal requires |journal= (help)
  15. ^ "ACAS - Wiki Journal Club". Retrieved 2021-02-11.
  16. ^ VascularWeb: New Vascular Surgery Training Paradigms

External links[edit]