Vascular surgery

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Vascular Surgeon
Occupation
NamesDoctor, Medical Specialist
Occupation typeSpecialty
Activity sectorsMedicine
Description
Education requiredDoctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.)
 
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Vascular Surgeon
Occupation
NamesDoctor, Medical Specialist
Occupation typeSpecialty
Activity sectorsMedicine
Description
Education requiredDoctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.)

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. 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. 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 manage surgical disease of the heart and its vessels. Neurosurgeons and interventional neuroradiologists manage surgical disease of the vessels in the brain (e.g., intracranial aneurysms).

Evolution of endovascular surgery[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.

Common professional associations[edit]

Associated areas of interest and operative surgical practice for vascular surgeons are access surgery for hemodialysis and peritoneal dialysis, organ harvesting for transplantation, renal transplantation, pancreatic solid organ transplantation Organ transplant.

Vascular surgeons will frequently have close associations with specialist interventional radiologists for a combined treatment of certain conditions. The radiologists contribute to endovascular cases management, sometimes with angioplasty and stenting, but also in specific areas of expertise e.g. sclerotherapy for vascular anomalies and arteriovenous malformations (AVMs), coil embolization of bleeding visceral arteries in trauma or for occlusion of tumor-supplying arteries as a prelude to operation, CT-guided procedures such as lumbar chemical sympathectomy.

Common medical associations are the involvement providing surgical opinions and treatment for a multidisciplinary clinic with vascular surgeons, vascular nurses, wound management nurses, podiatrists, prosthetists, rehabilitation physicians, vascular physicians, endocrinologists, etc. to manage high risk foot disease patients.

Less common operative surgical associations are: sympathectomy (ETS, Endoscopic thoracic sympathectomy), lumbar sympathectomy, Hyperhidrosis surgery); vascular access for chemotherapy etc. patients; dialysis/ECMO (extra-corporeal membrane oxygenation) for patients in Intensive Care Wards; vascular mobilization for access associated with other specialist operations e.g. extensive orthopedic spinal and pelvic surgery, retroperitoneal cancer dissections, renal tumor surgery.

Vascular surgery in the Third Millennium[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.

Breadth of discipline[edit]

Vascular surgery
Intervention
ICD-9-CM38-39
MeSHD014656
OPS-301 code:5-38...5-39

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.

CountryStandards bodyProfessional representationMinimum Length of training (post intern)
Australia and New ZealandRoyal Australasian College of SurgeonsAustralian & New Zealand Society of Vascular Surgery (ANZSVS)6 years
United KingdomRoyal College of Surgeons of England, Royal College of Surgeons of EdinburghVascular Society of Great Britain and Ireland http://www.vascularsociety.org.uk/8 years
USAAccreditation Council for Graduate Medical Education (ACGME), American Board of Surgery, American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS), American Osteopathic Board of SurgeryMultiple vascular societies5 years ( 4 via 5-year integrated Vascular Surgery Residency)[1]

Research[edit]

Research in treating vascular disease is exploring new areas, such as minimally invasive techniques which are less risky and speed a patient's recovery time. Vascular surgeon Kenneth Ouriel studied methods like these as part of a National Institute of Health grant to study thrombosis; results from this large, multicenter randomized trial of clot busting therapy treatments were published in the New England Journal of Medicine in 1998.[2][3][4][5]

Surgical procedures[edit]

By no means exhaustive, but below are a number of common procedures and indications for vascular surgeons.

Indication/diseaseProcedure
Abdominal aortic aneurysmOpen AAA repair

Endovascular Aneurysm Repair (EVAR)

Carotid stenosisCarotid endarterectomy

Carotid stenting

Varicose veinsVein stripping

Sclerotherapy and Foam sclerotherapy or Endovenous Laser Treatment, radiofrequency vein ablation

Ambulatory phlebectomy

Peripheral arterial occlusive diseaseAngioplasty with/out Stenting

Bypass surgery Endarterectomy Atherectomy

Acute limb ischaemiaBalloon embolectomy

Thrombectomy

Bypass surgery

Aortic dissectionOpen repair

Thoracic Endovascular Aneurysm Repair (TEVAR)

Major trials[edit]

- Edinburgh Artery Study. *Highwire results for Edinburgh Artery Study

- Netherland Vascular Study.[6]

- Framingham heart study. Highwire results for Framingham heart Study

- MASS Trial. – the Multicentre Aneurysm Screening Study (MASS) trial. Four centres (about 70000 men); screening (and treatment) vs. control group. AAA-related mortality in the screening arm reduced by about 40%; emergency ruptured AAA reduced by about 70%; disruption to elective work was reduced; and better management of risk factors and ITU/HDU beds. The overall survival benefits remain difficult to estimate, nevertheless, screening for AAA is recommended [level of recommendation: B].[7][8][9]

- 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.[10]

- 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.[11]

- 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.[12]

- HOPE (Heart Outcomes Prevention Evaluation) study - 4046 patients with PAD. In this subgroup, there was a 22% risk reduction in patients randomized to ramipril compared with placebo,which was independent of lowering of blood pressure.[13]

See also[edit]

References[edit]

  1. ^ VascularWeb: New Vascular Surgery Training Paradigms
  2. ^ "Dr. Kenneth Ouriel (biography)". New York-Presbyterian Hospital. 2009-09-22. Retrieved 2009-09-22. 
  3. ^ DENISE GRADY (March 18, 2004). "After Unusual Fatality, Transplant Expert Revives Career". The New York Times. Retrieved 2009-09-22. 
  4. ^ Ouriel, Kenneth (January 1995). Lower Extremity Vascular Disease (Hardcover) Kenneth Ouriel (editor). W.B. Saunders Company. pp. 440 pages. ISBN 978-0-7216-4749-4. 
  5. ^ Ouriel, Kenneth (September 26, 2005). Complications In Endovascular Therapy. Informa HealthCare. pp. 472 pages. ISBN 978-0-8247-5420-4. 
  6. ^ 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. 
  7. ^ VSGBI. Position statement for AAA screening 2004
  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. 
  9. ^ Fleming C, Whitlock EP, Beil TL, Lederle FA (1 February 2005). "Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force". Ann Intern Med. 142 (3): 203–11. PMID 15684209. 
  10. ^ "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. 
  11. ^ 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. 
  12. ^ 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. 
  13. ^ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (January 2000). "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators". N Engl J Med. 342 (3): 145–53. doi:10.1056/NEJM200001203420301. PMID 10639539. 

External links[edit]