By Daniel Walsh, MD

Daniel Walsh, MD
Daniel Walsh, MD

Vascular surgeons are a small group of surgeons (approximately 3000 in the US) who are specially trained to care for abnormalities of the arteries and veins other than those inside the skull or in the heart.  The diseases most commonly cared for by vascular surgeons include those of the veins and arteries of the leg and of the large blood vessels in the abdomen which become enlarged (aneurysms). 

Stroke prevention is a major focus for vascular surgeons as disease of the arteries in the neck (carotid arteries) is a common cause of stroke.  Many diabetics suffer problems with their legs and feet which require vascular surgery.  Smoking damages arteries anywhere in the human body so many smokers require treatment by a vascular surgeon.  Most commonly, smokers develop blockages in the arteries of their legs making it difficult for them to walk any distance. Other problems commonly cared for by vascular surgeons include venous problems such as blood clots and venous ulcers.

When a patient sees a vascular surgeon the doctor may look for signs that are indicative of peripheral artery disease, including weak or absent artery pulses in the extremities, changes in blood pressure in the limbs at rest and/or during exercise (treadmill test), and skin color and nail changes due to tissue ischemia.

In addition to the history of symptoms and the physical signs of peripheral artery disease described above, doctors can use imaging tests in the diagnosis of peripheral artery disease. These imaging tests include:

  • Doppler ultrasound — This form of ultrasound (measurement of high-frequency sound waves that are reflected off of tissues) that can detect and measure blood flow.
  • Angiography — An angiography is an imaging procedure to study the blood vessels of the extremities, similar to the way a coronary angiogram provides an image of the blood vessels supplying the heart. It is the most accurate test to detect the location(s) and severity of artery occlusion.

Because angiography is invasive with potential side effects (such as injury to blood vessels and contrast dye reactions), it is not used for initial diagnosis of peripheral artery disease. It is only used when a patient with severe peripheral artery disease symptoms is considered for treatment. A number of different imaging methods have been used in angiography examinations, including X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans.

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 traditional open surgery using wires and stents rather than the scalpel. This area of vascular surgery is called Endovascular Surgery. Endovascular and endovenous procedures now form the bulk of most vascular surgeons’ practices. 

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 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. 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 development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in general surgery. Previously considered a field within general surgery, it is now considered a specialty in its own right. As a result, there are two pathways for training in the United States. Traditionally, a five year general surgery residency is followed by a 1-2 year (typically 2 years) vascular surgery fellowship. An alternative path is to perform a five or six year vascular surgery residency. 

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. 

Daniel Walsh, MD is a Cardiovascular Surgeon.  He is a member of the medical staff at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and he sees patients at BMH every other Monday in the BMH Center for Cardiovascular Health.

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