Vascular surgery

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Vascular Surgeon
Occupation
Names Doctor, Medical Specialist
Occupation type
Specialty
Activity sectors
Medicine
Description
Education required

Vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The specialty evolved from general and cardiac surgery as well as minimally invasive techniques pioneered by interventional radiology. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system except that of the heart and brain. Cardiothoracic surgeons and interventional cardiologists manage disease of vessels of the heart. Neurosurgeons and interventional neuroradiologists manage surgical disease of the vessels in the brain (e.g., intracranial aneurysms).

Scope[edit]

Vascular surgery
Intervention
ICD-9-CM 38-39
MeSH D014656
OPS-301 code: 5-38...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 vericose veins. In some regions, vascular surgery also includes dialysis access surgery and transplant surgery.

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

Indication/disease Procedure
Abdominal aortic aneurysm (AAA) Open aortic surgery

Endovascular Aneurysm Repair (EVAR)

Carotid stenosis Carotid endarterectomy

Carotid stenting

Varicose veins Vein stripping

Sclerotherapy

Endovenous Laser Treatment

Ambulatory phlebectomy

Peripheral arterial occlusive disease Angioplasty with/out Stenting

Vascular bypass

Endarterectomy

Atherectomy

Acute limb ischaemia Balloon embolectomy

Thrombectomy

Vascular bypass grafting

Aortic dissection Open aortic surgery

Thoracic Endovascular Aneurysm Repair (TEVAR)

History[edit]

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, 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.

Evolution[edit]

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. 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 can now form the bulk of a vascular surgeon's practice.

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 of Vascular Surgery (SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZ SVS). Local societies also exist e.g. New South Wales Vascular and Melbourne Society of Vascular Surgeons (MVSA). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella e.g. Royal Australasian College of Surgeons (RACS).

SIR (Society of Interventional Radiology) remains intimately involved with the practice of endovascular therapy. Many of its members form part of a multi-disciplinary team treating vascular disorders alongside vascular surgeons. Although in many parts of the world vascular surgeons have evolved to now work alone.

Currently[edit]

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. 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 USA 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.

An emerging trend based on such venous clinics is the treatment of varicose veins by non-vascular surgeons e.g. cosmetic physicians, phlebologists, radiologists, etc. These practices aim to offer a complete varicose and surface vein treatment without surgery.

Investigations[edit]

Major trials[edit]

  • Netherland Vascular Study[1]
  • MASS Trial – The Multicentre Aneurysm Screening Study (MASS) trial, which found reduced mortality after screening for abdominal aortic aneurysms in the UK.[2]
  • 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.[3]
  • 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.[4]
  • 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 prophylaxic against perioperative MI in aortic aneurysm surgery.[5]

Training[edit]

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.

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
United Kingdom Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh Vascular Society of Great Britain and Ireland http://www.vascularsociety.org.uk/ 8 years
USA 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)[6]
Italy 5 years

See also[edit]

References[edit]

  1. ^ 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. 
  2. ^ 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. 
  3. ^ "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. 
  4. ^ 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. PMID 8040955. 
  5. ^ 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. 
  6. ^ VascularWeb: New Vascular Surgery Training Paradigms

External links[edit]