Vascular surgery

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. Of note, Dr. Thomas Fogarty invented the balloon catheter which enabled 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 (e.g., EVAR) can now form the bulk of a vascular surgeon's practice.

The treatment of the aorta, the body's largest artery, dates back to Greek surgeon Antyllus, who first performed surgeries for various aneurysms in the second century AD. Modern treatment of aortic diseases stems from development and advancements from Michael DeBakey and Denton Cooley. In 1955, DeBakey and Cooley performed the first replacement of a thoracic aneurysm with a homograft. In 1958, they began using the Dacron graft, resulting in a revolution for surgeons in the repair of aortic aneurysms. He also was first to perform cardiopulmonary bypass to repair the ascending aorta, using antegrade perfusion of the brachiocephalic artery.

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 for 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).

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. Historically performed by interventional radiologists, vascular surgeons have become increasingly proficient with endovascular methods.[1] 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 United States 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.

NHS England conducted a review of all 70 vascular surgery sites across England in 2018 as part of its Getting It Right First Time programme. The review specified that vascular hubs should perform at least 60 abdominal aortic aneurysm procedures and 40 carotid endarterectomies a year. 12 trusts missed both targets and many more missed one of them. A programme of concentrating vascular surgery in fewer centres is proceeding.[2]

• Netherland Vascular Study[4]
• MASS Trial – The Multicentre Aneurysm Screening Study (MASS) trial, which found reduced mortality after screening for abdominal aortic aneurysms in the UK.[5]
• 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.[6]
• 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.[7]
• 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 prophylactic against perioperative MI in aortic aneurysm surgery.[8]