About Vascular Surgery

Vascular Surgery has developed dramatically over the last 60 years as have all branches of surgery, often driven by battlefield conflict, and by amazing technological developments.

It involves the investigation and management of diseases and abnormalities in all the arteries and veins of the body apart from the heart(Cardiac surgery) and the brain (Neurosurgery).

The Vascular Surgeon these days will work closely with a Radiologist whose specialty is the imaging of blood vessels by Xray, Ultrasound, and Magnetic Resonance.

The commonest arterial conditions are blockages of arteries needing clearing or bypass, and aneurysms, which are blowouts of the arteries.

The usual problems with veins are related to Varicose Veins and thrombosis.

The most important and common issues are discussed in more detail here.

 

Carotid Surgery

Stroke is one of the most feared of all afflictions.

In a number of cases stroke is the result of a travelling clot which comes from the carotid artery in the neck and ends up in the brain. The underlying problem is the buildup of plaque (hardening of the artery, called "atheroma") at the point in the neck where the carotid artery branches in two. This buildup of plaque causes gradual narrowing of the artery and disruption of smooth flow of blood. As a result tiny amounts of blood clot form in the artery, and when a fragment of this clot breaks loose and travels up to the brain it can cause damage to that portion of the brain resulting in a stroke.

Fortunately this event is often preceded by a temporary "mini stroke" (transient ischaemic attack or "TIA") which allows time for intervention to prevent a permanent stroke.

So when carotid narrowing (or "stenosis") is found a decision about management needs to be made. This mainly depends on the degree of narrowing in the artery which is measured using an ultrasound examination. If the narrowing is mild then it can be managed with medication, but if there is more than 70% narrowing then surgery offers the safest treatment. Left untreated at this level there is considerable risk of stroke.

It has been clearly shown in large studies in both Europe and the US that surgery dramatically reduces the risk of major stroke when this severe degree of stenosis is present.

In recent years there has also been a move to offer "stent" relining of the carotid instead of surgery. This is available but currently surgery remains the much safer option for most patients unless there is a very good reason to avoid operation.

The operation is known as Carotid Endarterectomy and is a very common procedure. In the operation the surgeon cleans out the inside of the artery and then repairs the artery with a small patch graft. The operation lasts about 90 minutes and recovery is rapid, with the patient ready to leave hospital after a day or two in most cases. If both sides of the neck need doing the second side can be done after a few weeks.

 

Aneurysm

An aneurysm is a balloon-like blow out of a blood vessel, usually an artery.

The biggest artery in the body is the Aorta which is the high pressure main artery coming from the heart and distributing blood to all parts of the body. Aneurysms can occur anywhere in the aorta but most are seen in the lower aorta deep inside the abdomen. These are known as AAAs and can cause of sudden death if they burst. These AAAs cause almost no symptoms at all before rupture and they are often diagnosed only by chance, usually if an xray or scan is done for some other reason.

AAAs are 3 times more common in men than women and sometimes run in families so there is a hereditary element. It is likely there is some tissue defect at a molecular level. Little else is known for sure why people get an aneurysm except that like most vascular problems they are more common in smokers.

Because rupture of an aneurysm can be such a lethal event it is important to diagnose the condition early and to plan prevention. We know that aneurysms grow slowly and they hardly ever rupture until they reach a certain size - around 50mm diameter. This is easily measured using an ultrasound scan. By comparison the normal aorta is about 20mm. So if an aneurysm is smaller than 50mm we normally advise a watching policy with annual measurement by simple ultrasound scan.

Patients with small AAAs often ask what can be done to stop an aneurysm from growing. Unfortunately there is no known way to influence this.

Repair is quite a major procedure so it is not usually advisable to rush into repair of an AAA until really necessary on grounds of size. This is traditionally done by opening the abdomen up and sewing a dacron graft in place of the aneurysm. This is a big operation but one which is very common. In Auckland alone over 120 of these will be done every year.

In the last couple of decades an alternative keyhole repair technique has been introduced and is being continually improved. This is "Endoluminal Stent" repair or "EVAR". The use of a stent has several advantages for patients who qualify, but not everyone is suitable because of the exact shape of the AAA - about half our patients are currently suitable. This procedure usually only means an overnight stay in hospital and rapid return to normal activity, but the cost is much higher due to the complexity of the equipment and the stent itself. As many as 1 in 5 of these patients will also need further adjustment procedures at a later date and all need regular
follow up scans for the rest of life.

 

Claudication

This is pain in the muscles (calf, thigh, or buttock) of the leg on exercise, and is due to reduced blood supply to legs.

This causes heavy cramp-like discomfort when there is demand for increased flow during exertion.  It can vary from quite mild to very severe, short distance or long distance.  In true vascular claudication it is worse going up hills or stairs and eases off rapidly on resting for a while. A similar type of claudication discomfort can be due to nerve compression in the spine but may occur at rest or be worse walking down hill.  Rarely both causes can be present at the same time and scans will be needed to sort this out. Vascular claudication is due to narrowed or blocked arteries nearly always as a result of plaque from cigarette smoking, although this is not the only cause.

Management involves stopping smoking, as well as walking programmes, lowering cholesterol, weight control, and some form of blood thinning medication such as a small dose of aspirin daily. If these things are not successful then we can use other things such as balloon angioplasty (stretching open narrowed areas), or surgery to clear blockages.  Before planning this it will be necessary to do various scans to see the extent of any blockages.

Diabetic patients and those with high blood pressure are especially at risk of this sort of problem and these issues need careful control along with the other measures listed above.

In the worst cases surgery will be needed to clear or bypass blockages.

 

Varicose Veins

These are the most common of all vascular problems and at Vascular Surgical we have more experience in their management than any other practice in New Zealand.

We are Affiliated Providers for Southern Cross.

The most common symptoms from varicose veins are aching in the lower legs after periods of standing and in hot weather. Itching over the veins is also common. When the condition is more advanced skin changes can occur around the ankle region with dermatitis, staining and even ulceration.

Assessment of varicose veins for treatment involves an ultrasound scan to confirm the underlying cause of the problem which is most often a leaking one way valve in the groin where the blood in the veins goes from the superficial skin veins into the deeper body veins. When this valve leaks there is significant back pressure on the skin veins which get stretched into large varicose veins.

Treatment options fall into 4 main groups.

1. The least invasive but possibly least satisfactory is to fit surgical compression stockings which control the tendency for the veins to become enlarged.

2. The second method is surgery which is the gold standard.

This is not usually regarded as major but still needs to be done with care and good planning. In this the offending veins are surgically removed. Either day stay or overnight in hospital, it requires a general anaesthetic, and is surprisingly pain free. There is no period of immobility required and time off work is only a few days.

3. Thirdly, injections can be used to close off the veins using a sclerosing substance.

This can be done without anaesthetic and needs no time off work. Compressive dressings need to be worn for approximately 3 weeks after each session. Very large thigh veins do not respond so well to this method.

4. Finally it is also possible to treat veins with either radio waves or laser which works very much like injections but instead of a sclerosing substance a fibre is inserted inside the main veins to make them to shrivel.

The main advantage of this technique is that it is done under local anaesthetic so again no time off work. However only straight veins can be treated this way so follow up surgery or injections are often necessary to completely eliminate tortuous veins.

Comparisons of groups of patients treated with the different methods show little advantage for any method in terms of recurrence of veins, but each method has its advantages and disadvantages.
 

 

Hyperhidrosis (excessive sweating)

This is a distressing condition which can affect different parts of the body to varying degrees.

It is more common in young women and may affect the hands, the face, the armpits or other sites either together or singly. It can occasionally be so severe as to appear as if the hands had just been under a tap.

Sufferers will tell of difficulty with a wide range of activities including social contact, handling paper, writing, keyboards, musical instruments, steering wheels and sporting equipment. If the feet are the affected area it is difficult, even dangerous, to walk barefoot on smooth floors, quite apart from rapidly destroying shoes. This condition in its worst form can even cause complete social withdrawal.

Treatment of hyperhidrosis can be by several methods, not all of them straightforward or even effective in each case. Where previous treatments for face or hand sweating have been unsuccessful a very simple surgical procedure known as sympathectomy is available. It can also be used for foot sweating if this is the area most affected.

Sympathectomy however is not without side effects and very careful assessment is needed before a decision is made to go ahead. At Vascular Surgical we can provide extensive information and background on all options in treatment of this distressing condition.