Vascular surgery
Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular (minimally invasive) techniques and medical management of vascular diseases - unlike the parent specialities. 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. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.[1]
Vascular surgery
Abdominal aortic aneurysms can be classified as infrarenal, juxtarenal, pararenal or suprarenal as depicted in the illustration.
The Crawford Classification (Extent I-IV) and the Safi modification (Extent V) for thoracoabdominal aortic aneurysms is pictured above.
Management of venous diseases[edit]
Chronic venous disease[edit]
Chronic venous insufficiency is the abnormal pooling of blood in the lower extremity venous system which can lead to reticular veins, varicose veins, chronic edema and inflammation among other things. Population data suggests that chronic venous insufficiency affects up to 40% of females and 17% of males.[21] When chronic insufficiency leads to pain, swelling and skin changes it is referred to as chronic venous disease. Chronic venous insufficiency (CVI) is distinguished from post-thrombotic syndrome (PTS) in that CVI is primarily an issue of valvular incompetence of the superficial or deep veins whereas PTS may occur as a long-term complication of deep venous thrombosis.[22]
The vascular surgeon has several modalities to treat lower extremity venous disease which including medical, interventional and surgical procedures. For instance, venous ulceration may be treated with Unna's boots, superficial venous reflux with radiofrequency, laser ablation or vein stripping if indicated. When indicated, insufficiency in the deep veins may be treated with reconstruction of the venous valves with internal or external valvuloplasty.[23]
Compressive venopathies[edit]
Compression of large veins by adjacent structures or masses may lead to distinct clinical syndromes including May–Thurner syndrome (MTS), nutcracker syndrome and superior vena cava syndrome to name a few. Treatment modalities include venography, intravascular ultrasound and venous stenting as well as more invasive open venous reconstruction and bypass.
Management of hemodialysis access[edit]
Patients with chronic kidney disease may have progression of disease which requires renal replacement therapy to filter their blood. One strategy for this therapy is hemodialysis, which is a procedure that involves filtering a patient's blood to remove waste products and returning their blood back to them. One method which avoids repeated arterial trauma is to create an arteriovenous fistula (AVF). The first procedure described for this purpose is named the Cimino fistula, after one of the surgeons who first had success with it. Vascular surgeons may create an AVF for a patient as well as undertake minimally invasive procedures to ensure the fistula remains patent.