A Few Words

About Vascular Surgery

Vascular surgery encompasses the diagnosis and comprehensive, longitudinal management of disorders of the arterial, venous, and lymphatic systems, exclusive of the intracranial and coronary arteries. Diplomates in vascular surgery should have significant experience with all aspects of treating patients with all types of vascular disease, including diagnosis, medical treatment, and reconstructive vascular surgical and endovascular techniques. In addition, diplomates in vascular surgery should possess the advanced knowledge and skills to provide comprehensive care to patients with vascular disease; understand the needs of these patients; teach this information to others; provide leadership within their organizations; conduct or participate in research in vascular disorders; and demonstrate self-assessment of their outcomes.

The vascular surgeon must have advanced knowledge and experience with the management of vascular problems including:

  1. All elements of clinical evaluation, including non-invasive testing such as plethysmography, duplex ultrasonography, magnetic resonance imaging, CT scans, angiography, and other diagnostic tests utilized in the diagnosis of vascular disease.
  2. Comprehensive management of vascular disease to include screening and surveillance, medical management, drug therapy, risk factor management, and wound management including amputations, as well as other adjunctive procedures.
  3. Indications and techniques relating to the open and endovascular treatment of vascular disorders, to include the entire spectrum of interventions used to treat vascular disorders, including such disorders as occlusive, aneurysmal, and inflammatory disease, trauma, and neurovascular compressive syndromes involving the arteries and veins of the body (excluding the intracranial and coronary arteries). These include the aorta and its branches, as well as the arteries of the neck, pelvis and upper and lower extremities, and the venous system.
  4. The critical care of the vascular surgery patient.

Evolution of Vascular Surgery –

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.

Dr. Edward “Ted” Dietrich, one of Dr. DeBakey’s associates, went on to pioneer many of the minimally invasive techniques that later became hallmarks of endovascular surgery. Dietrich later founded the Arizona Heart Hospital in 1998 and served as its medical director from 1998 to 2010. In 2000, Diethrich performed the first endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm. Dietrich trained several future leaders in the field of endovascular surgery at the Arizona Heart Hospital including Venkatesh Ramaiah, MD who served as medical director of the institution following Dietrich’s death in 2017.

Current Scenario In Vascular Surgery –

Arterial and venous disease treatment by angiographystenting, and non-operative varicose vein treatment sclerotherapyendovenous 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. 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.

Vascular surgery encompasses surgery of the aortacarotid arteries, and lower extremities, including the iliacfemoralvascular trauma and tibial arteries. Vascular surgery also involves surgery of veins, for conditions such as May–Thurner syndrome and for varicose veins, vascular surgery also includes dialysis access surgery and transplant surgery.

VASCULAR SURGERY IN INDIA –

The Challenge
India: 1.38 billion people, one sixth of humanity and a population two and a half times that of Europe with a per capita gross domestic product (GDP) of $2 100 as against $45 000 for the European Union (EU). The healthcare scenario in India is very different from the West for a variety of reasons. India is a low income country with vast economic, educational, nutritional and cultural inequities. India has a young population with average age of 35 years. Only 6% of its population is over 65 years though this does constitute 78 million people (more than the population of France), and yet, we do not perform as many vascular procedures! India has about 400-500 active vascular surgeons. This equates to around three million population to every specialist!

Vascular diseases in India

India is in the centre of the global Diabetes pandemic. The diabetic population has increased threefold to 77 million over the last three decades. With early onset as part of the metabolic syndrome, diabetes is now the predominant cause of limb ischaemia.

There is a high prevalence of chronic kidney disease with over 200 000 new patients starting haemodialysis every year. Consequently, vascular access related procedures are a significant component of vascular practice. In many centres this may make up 50% of vascular work.

Venous disease was under appreciated in India for many decades. It was believed that deep venous thrombosis (DVT) was uncommon in India. Vascular surgeons have led the way in debunking this myth.

Following many decades of neglect there is a large burden of undiagnosed and untreated chronic venous insufficiency, often due to post thrombotic syndrome. There was early adoption of deep venous reconstruction for chronic venous insufficiency and currently Indian vascular surgeons frequently treat acute DVT with thrombolysis and venous angioplasty. Meanwhile the advent of endovenous ablation has resulted in a steep rise in the number of patients treated for varicose veins, mainly by non-vascular surgeons.

While there are ample skills and infrastructure to treat all types of aortic aneurysms and dissections with practically all options including open surgery, endovascular and hybrid repairs, the numbers remain small due to costs and also possibly to the lower prevalence of disease. Aortic aneurysm workload comprises 1-10% in different vascular units and is about 30% in a couple of public hospitals. Computed tomography review of a general population documented a significantly smaller normal infrarenal aortic diameter compared with Western populations. A very low incidence of aortic aneurysms was also observed even in a high risk peripheral arterial disease population (unpublished data). This suggests that the Indian aorta is smaller and does not undergo aneurysmal change as frequently as in Caucasian populations. Consequently, many vascular surgeons adopt a smaller diameter threshold for intervention, due to a perceived higher risk of rupture given the smaller native aortic diameter. Aortic occlusive disease is seen in large numbers, in younger populations and typically tends to be thrombotic.

Vascular emergencies include peripheral embolism, trauma and the septic diabetic foot. Non-traumatic acute limb ischaemia is typically cardio-embolic due to rheumatic heart disease, untreated atrial fibrillation and ischaemic heart disease. Vascular trauma is a major cause of limb loss in India. Most cases of vascular trauma involve limbs with orthopaedic injuries and are the result of road traffic accidents, due to the large number of two wheelers and lack of discipline on the roads. Gunshot wounds are uncommon except in areas with insurgency and that too is on the decline.

Most Vascular surgeons are located mainly in well equipped private hospitals in metropolitan cities. Some are moving to smaller cities and actually keeping quite busy. There is sever lack of dedicated vascular centres in India.

Vascular surgeons in the private sector are quite readily accessible. Unlike many other countries, patients can consult a vascular surgeon through a referral or directly in a day or two. It is usual to have a consultation, pre-operative imaging, and investigations on the same day, and an elective vascular procedure within a day or two.

Open vs. Endovascular

Over the years, vascular care in India has trended towards endovascular and the majority of vascular units now treat 80% of aneurysms and 50 to 90% of occlusive disease with endovascular techniques. Cardiologists and Interventional Radiologists too have a share of endovascular work. Unlike Western economies, the cost of human resources in India, such as nurses and technicians is lower than the cost of equipment and consumables such as guidewires, balloons and stents, more than 80% of which are imported. Therefore, open surgery is less expensive than endovascular interventions. Most centres in India reuse a significant volume of endovascular material to keep costs down and make therapy accessible to a wider population.

The economic pressure to deliver optimum care at a low cost generates innovation and uniquely Indian solutions – famously referred to as “jugaad” (flexible approach to solve a problem using limited resources in an innovative way). A repurposed catheter used for thrombolysis is an example.

We also learn to be frugal and use minimum hardware. Cath lab access is a problem for some vascular surgeons but is gradually being solved. Most of us started endovascular procedures using basic image intensifiers in operating rooms (ORs) and then in cardiac catheter labs that were typically available late in the evenings. Many vascular surgeons now have dedicated labs for vascular work. High quality mobile C arms in operating rooms make very economical hybrid ORs.

Given these challenges, the majority of healthcare costs are borne by the patients and can be a huge economic burden on families. This creates difficult ethical dilemmas with no easy answers. Surgeons often try to help with support from hospital managements, charitable organisations and from their own professional fee. Unfortunately, in many situations, treatment decisions are not purely scientific and involve significant financial and accessibility considerations.

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