Vascular surgery

Vascular surgery is a sub-specialty of general surgery that deals with diseases of the arteries and veins. Patients can present with either acute or chronic problems. Acute vascular problems are usually either life or limb threatening and require prompt attention and intervention to avoid loss of life or limb.

Arterial disease

The underlying cause of arterial disease is mostly atherosclerosis: hardening of the wall of the vessel which eventually leads to either narrowing of the vessel or weakening of the vessel wall which will then lead to an aneurysm (dilatation of the artery) forming.

The risk factors for developing atherosclerosis (and therefore arterial disease) are the following:

Major:

• Smoking
• High blood pressure
• Diabetes
• High cholesterol

Minor:

• Age
• Obesity
• Being a male
• Hypercoagulability
• High homo-cysteine levels in the blood

Treating vascular disease will usually employ one or a combination of the following strategies:

• Lifestyle modification (weight loss, exercise, cessation of smoking)
• Medical management (controlling diabetes, hypertension, high cholesterol, treatment to thin the blood, etc.)
• Endovascular therapy (stenting or angioplasty)
• Open surgery (bypass or aneurysm repair procedures)
• Amputation (last resort)

Endovascular therapy: The importance and availability of endovascular therapy has grown exponentially over the last 2 decades. After gaining access through a peripheral artery the entire vascular system can be accessed. Specially designed balloon-tipped catheters can then be used to dilate narrow areas in the arteries and ‘stents’ can be deployed and left in the arteries to keep them open.

Open surgery: Surgery still plays a major role in the treatment of arterial disease, usually where endovascular therapy is not possible or has failed. Surgery usually entails either an endarterectomy (opening the artery and cleaning out the inside) or a bypass procedure. With a bypass procedure a segment of the patient’s own vein or a synthetic tube is used to bypass the diseased segment of the artery and restore adequate blood flow.

Amputation: Amputation is usually a last resort. It might be done because the disease is untreatable or because the limb is no longer salvageable. The aim will always be to preserve as much limb function as possible.

Arterial disease will usually present as either peripheral vascular disease or aneurysmal disease.

Peripheral vascular disease

Peripheral vascular disease will mostly present as narrowing of the arteries delivering blood to the legs. Patients may present with any of the following complaints (in order of severity):

• Asymptomatic

Early disease will not produce any clinical symptoms

• Intermittent claudication

Claudication is pain experienced during any form of exercise (such as walking). It is usually felt in the calves or buttocks and happens because the narrowed vessels cannot meet the muscles’ increased demand for oxygen during exercise. The distance you can walk is proportional to the severity of the disease.

• Incapacitating claudication

Claudication is termed incapacitating when it leads to impairment in the patient’s normal day-to-day functioning.

• Critical limb ischaemia

Critical ischaemia is present when there is either ‘rest pain’ (pain at rest that is usually severe enough to keep the patient awake at night) or tissue loss (either a chronic ulcer/wound or the presence of gangrene).

Treatment

• Asymptomatic & intermittent claudication

Risk factor (see above) modification and a structured exercise program is the mainstay of treatment. This requires dedication on the part of the patient, but will lead to an improvement in symptoms.

• Incapacitating claudication

The determination of what is incapacitating will differ from patient to patient. When to intervene in this situation can be a very difficult decision. The advantages of an intervention need to be weighed against the potential complications. The patient will have to make an informed decision after thorough discussion with the surgeon.

• Critical limb ischaemia

Intervention will always be necessary in this group if an amputation is to be avoided. Intervention can take the form of either endovascular therapy or open surgery (see above).

Aneurysmal disease

Atherosclerosis causes weakening of the arterial wall. Due to the high pressures generated in the arterial system this weakening can lead to dilatation of the vessel. Once the diameter of the vessel has increased by more than 50% there is an aneurysm. Aneurysms can occur in any artery, but mostly occurs in the abdominal aorta and the major blood vessels supplying the legs. Aneurysms are mostly asymptomatic when small, but can cause problems in the following ways:

• Pain

As the size increases so does the chance that the aneurysm will cause symptoms. The aneurysm can lead to mechanical back pain due to erosion into the vertebrae, but mostly pain is a sign of impending rupture and should be investigated as a matter of urgency.

• Thrombosis

This is not a common complication, but because of turbulent flow in the aneurysm there is a risk that the aneurysm will become blocked by blood clots. Depending on the site this will usually lead to a patient presenting with a threatened limb (if blood flow is not promptly restored the limb will need to be amputated).

• Embolism

Because of turbulent flow in the aneurysm blood clot can form in the wall of the aneurysm. If a piece of clot then breaks off it can cause obstruction further downstream and lead to ischaemia lower down in the limb.

• Rupture

This is the most feared complication. In most cases the bleeding will be contained by surrounding structures and organs and the patient will have a 60-80% chance of survival if he seeks prompt medical attention. If the rupture occurs freely into the peritoneal (abdominal) cavity the chances of survival deteriorates dramatically.

Treatment

• Asymptomatic aneurysms

Small aneurysms detected incidentally have a low risk of rupture and may be observed only. This would entail 6 monthly ultrasound evaluation to determine size. A diameter of > 5.5cm in males and > 5.0 cm in females or enlargement of > 0.5cm in 6 months would imply a significant risk for rupture and usually warrant a repair.

• Symptomatic aneurysms

If an aneurysm is truly symptomatic it needs to be repaired irrespective of size. This can be done with open surgery or by means of endovascular stenting.

• Ruptured aneurysms

Ruptured aneurysms are dire emergencies and require immediate intervention if the patient is to survive. Even in the best of centres the mortality rate remains high.

Venous disease

Varicose veins are one of the most common medical conditions. In some patients it leads to cosmetic problems alone. In most, however, it is a source of discomfort, pain, swelling and thrombophlebitis (clotting and inflammation of the vein). It may also lead to skin changes, ulcers, bleeding and disability.

Treatment

Varicose veins occur as a result of incompetent valves in the veins that allow backflow of blood and therefore abnormally high venous pressure to develop. It is not possible to repair these delicate valves. The aim of treatment would be to divert blood flow to the healthy deep venous system. This can be accomplished either be removing the diseased segment of vein (tying and stripping of the vein), performing sclerotherapy (injecting the vein with a substance that will induce scarring and obliteration of the lumen) or by applying heat to the vein from the inside to obliterate the lumen (the Venefit / Vnus procedure).

Tying and Stripping

This is a surgical procedure that is usually done in theatre under full anesthetic. An incision is made in the groin and the major superficial vein of the leg is tied off and then usually also ‘stripped’ (pulled from the leg). Several small incisions are also made in the lower leg to remove some of the smaller veins that have also become dilated. A tight fitting dressing is then placed in theatre to minimize bruising.

Sclerotherapy

Sclerotherapy is used to treat smaller varicose veins called ‘spider veins’ (telangiectasis) or reticular veins (slightly larger blue veins). Larger varicose veins are always best treated by the Venefit / Vnus procedure or tying and stripping. In some instances it might be necessary to treat larger varicose veins first before sclerotherapy of smaller veins can be done successfully. Sclerotherapy is an office-based procedure where very small needles are used to inject a special solution directly into the affected veins. This then causes the walls of the veins to stick together and blood flow is diverted to other, healthy veins.

The Venefit / Vnus Procedure

This revolutionary minimally invasive procedure involves the insertion of a thin, flexible tube (‘ClosureFast’ catheter) into a diseased vein to seal it shut using heat (this process is called radiofrequency ablation). Blood that would normally return toward the heart through these veins will then travel through other, healthy veins instead. Over time the treated vein shrinks and is absorbed by the body. Compared with surgical options like ligation and vein stripping, endovenous ablation results in less pain and quicker recovery time. The procedure can be done in theatre or in the doctor’s rooms under local anesthetic and sedation.

Advantages of the Venefit / Vnus procedure:

Minimally invasive

The Venefit procedure eliminates the need for groin surgery and general anesthesia. The procedure also results in little to no scarring and is generally performed using local anesthesia in a vein specialist’s office or an outpatient surgical facility.

Less pain, less bruising, faster recovery

The 2009 RECOVERY Study compared the experience of patients treated with the ClosureFast (Venefit) catheter and those treated with the 980 nm laser. The study demonstrated:

• Less pain, bruising and complications with the ClosureFast catheter
• Up to four times faster improvement in patients’ quality of life with ClosureFast catheter versus laser based on a quality of life questionnaire

Other studies have shown that patients receiving the Venefit procedure return to normal activity and work significantly faster than those undergoing vein stripping.

Excellent clinical outcomes

The ClosureFast catheter has been shown in a prospective, international multi-center study to be 93% effective at three years using Kaplan Meier analysis.

Excellent cosmetic results

Because of the minimally invasive nature of the procedure there is only a small puncture wound needed in the majority of cases. The obliterated vein is also left in place and not stripped which results in virtually no post-operative bruising.