Vascular/Endovascular Surgery

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Peripheral Vascular Surgery

The function of the blood vessels in the body is to transport oxygenated and deoxydenated blood between the heart and the rest of the body. The heart's job is to pump the blood to different parts of the body through these blood vessels.
Peripheral Vascular surgery is a superspeciality branch of surgery that deals in a holistic manner with all diseases of these blood vessels (i.e. arteries and veins) of the entire body except the blood vessels of the heart and brain.
Peripheral vascular surgery is now a separate speciality from Cardiothoracic and Vascular Surgery (CTVS) which is now Cardiovascular and thoracic surgery as per GOI notifications. The Cardiac Surgeon/ Cardiologist deals with the diseases of the heart, whereas the Peripheral Vascular Surgeon deals with diseases of all the other blood vessels of the body.
Peripheral Vascular Surgery is not just about fixing blocked pipes (i.e. arteries and veins). It also involves post operative wound care, foot care, rehabilitation and preventing recurrent ulcers/ gangrene which can be a cause for major limb loss despite adequate vascularity.
The scope of peripheral vascular surgery is extensive. The diseases treated range from Burgers disease to atherosclerosis, vasculitis etc. and varicose veins, Deep Venous Thrombosis and its resultant management either in the acute or in chronic stage, Creation and maintanence of dialysis accesses (arterio-venous fistulas) and tackling problems of central venous stenosis resulting from long term hemodialysis catheters.

How does peripheral arterial disease occur?

Atherosclerosis affects the arteries of the entire body and not just the heart. Atherosclerosis involving the Carotid arteries can lead to stroke which can be of varying intensity (from Transient Ischemic Attack to full stroke). Involvement of the arteries to the upper limbs can lead to decreased blood flow to the hands and can lead increasing pain in the hands while working/ writing etc.
Atherosclerosis affects most commonly the arteries in the abdomen (aorta) and the lower limbs. Atherosclerosis occurs extensively in people who smoke cigarettes/ beedi/ hookah etc. and involves the aorta, arteries to the intestines and kidney, and also arteries in the legs most commonly upto the knees, although this is not exclusive. Occasionally this is also seen in patients who do not smoke tobacco in any form.
Degeneration of the arterial wall caused by atherosclerosis can also lead to aneurysms arising in various arteries of the body eg. Abdominal and thoracic aorta, popliteal artery, femoral artery and rarely in other areas of the body. Aneurysms are dangerous due to their risk of rupture (in the abdominal and thoracic aorta) and thrombosis (popliteal and femoral arteries). Rupture can be life threatening whereas thrombosis can be limb threatening.
Diabetics suffer from extensive atherosclerotic involvement of the arteries of the legs below the knees and often with extensive calcium deposition in the arteries.
Diabetics who smoke can have involvement of the entire arterial tree which can be very extensive.
Occasionally peripheral arterial disease develops in young individuals who smoke tobacco in any form (beedi/ cigarettes/ hookah/ cigars etc.) and is particularly severe leading to a very high risk of limb loss due to extensive gangrene.
Even more rarely is thrombotic occlusion of these arteries encountered, what is known as LEG ATTACK, which is very similar to heart attack, but if not treated appropriately in a timely manner can have disastrous complications like major limb amputation, renal failure, pulmonary edema, heart failure etc.

Endovascular Surgery

Endovascular surgery deals with procedures performed on the peripheral blood vessels in a non surgical manner with wires, catheters, balloons and stents. Both diseases of the arteries and veins are dealt with. The procedure does not involve any incisions or sutures, has minimal blood loss, shorter operative times, and faster return to activities of daily living and recreational activities. Areas of the body that often are difficult to treat due to repeated past surgical interventions or if surgical intervention can be life threatening or occur in remote locations which are difficult to access surgically can often be treated rapidly and with minimal morbidity with endovascular techniques.
The techniques evolved with treatment of diseases of the heart and have progressed rapidly to tackle practically all diseases of the peripheral arterial and venous system. There has been a rapid advancement in the technologies utilized in dealing with the diseases of the peripheral vascular system.
Angioplasty and stenting can be performed in practically any arterial tree with good short and long term results.
Equating coronary arterial interventions with peripheral vascular interventions is like equating apples and oranges. The techniques, wires, catheters and all other ancillary hardware used are different. Every area of the body treated has its own set of different hardware that is required, and techniques and methods used in one area cannot be utilized in another. Performing endovascular interventions is not just about getting a wire across because the vessel is very big, the right procedure has to be chosen for the right patient.

Vascular ultrasound

Peripheral vascular ultrasonography forms a very important aspect of the vascular physiological lab. Arterial or venous duplex/ triplex examinations are used for preoperative, intraoperative and post operative assessment of the disease and for the follow up of the treatment administered.
Preoperatively, treatment planning can be carried out to eliminate intraoperative surprises and decrease the possibility of missing out on problems that can cause post operative problems.
Intraoperative use of the ultrasound is mandatory while performing endovenous ablation of varicose veins. This ensures completeness of the treatment thereby reducing the possibility of recurrence of the disease.
I perform my vascular ultrasounds myself just like the cardiologist likes to perform their own echocardiography. It gives me a complete picture of the problem at hand and appropriate treatment planning can be performed.