Vascular surgery

Arterial surgery

As the name suggests, it treats arterial lesions. In more than 90% of cases, they are lesions of atheromatous origin and usually occur in bifurcations.

As well to age, sex and genetics, the four major risk factors of atherosclerosis are smoking, diabetes, hypercholesterolemia and arterial hypertension. 

These lesions may be narrowing (stenoses), slowing the blood flow; occlusions (thromboses), responsible for acute ischaemia in an arterial territory (sudden lack of oxygenation); dilations known as aneurysms; or even dissections. After an anamnesis and a full clinical examination, in the first instance, the assessment is based on a Doppler ultrasound with the calculation of the ABI (ankle-brachial) index in particular.

Depending on the pathology (type and location of lesions), but also on the patient (age, history, etc.), the surgeon may proceed with:

• conventional surgery (opening the artery): endarterectomy or bypass.
• Minimally invasive percutaneous surgery using endovascular techniques: angioplasty with or without recanalisation and/or stenting. This surgery is performed by inserting balloons, stents or endoprostheses into the vessel, allowing it to be treated without opening it

In all cases, surgical treatment is combined with medical treatment and control of risk factors. In particular, this includes stopping smoking, making lifestyle improvements and more specific antiplatelet medication.    

Depending on the location of lesions, symptoms may be very varied. Carotid stenosis (of arteries vascularised the brain) may be responsible for:

• a transient ischaemic attack (TIA) with no sequelae, or
• a stroke with often dramatic consequences (hemiplegia, aphasia, visual impairment, etc).

If the narrowing is more significant than 70%, surgery is required. Here, the gold standard is endarterectomy, which consists of ablation of atheromatous plaque best performed under local/regional anaesthesia.

• Peripheral artery disease (PAD) of the lower limbs involves all arteries from the aorta to the very peripheral arteries of the feet and toes. It is responsible for intermittent claudication, a walking disorder. In more advanced stages, decubitus pain preventing sleep, necrotic cutaneous lesions and acute ischaemia may be experienced. With this pathology, in more than 70% of cases, treatment is endovascular (dilatation and/or stenting), but it may also involve an endarterectomy or a bypass.
• Aneurysms may affect all arterial territories. The most common are found in the infrarenal abdominal aorta. Often, there are no clinical symptoms. Aneurysms are discovered during paramedical exams. Where the aneurysm is larger than 50 mm, treatment is surgical. Depending on the patient, open surgery (inlay grafting) or insertion of a transfemoral aortic endoprosthesis may be chosen.

Other fields of intervention

The vascular surgeon is called upon in the treatment of stenoses of the renal and digestive arteries, deep vein thrombosis, or for the embolisation of pelvic varicose veins. The surgeon creates arteriovenous fistulas for dialysis.

The surgeon may also deal with thoracic outlet syndrome, arcuate ligament syndrome and trophic disorders, specifically, diabetic foot. Finally, they may be involved in surgical procedures or injuries where vessels are concerned. Lymphatic surgery occurs in exceptional circumstances. 

The variety of pathologies encountered and their diffusion mean that this speciality requires much expertise and experience in all conventional and endovascular techniques. It requires a complete medical environment with an angiologist, a radiologist, a cardiologist, an endocrinologist, a pulmonologist and, of course, an anaesthetist. It also needs high-performance technical facilities, complete with angio-CT, angio-MRI, cath lab, amplifier and state-of-the-art carbon table.