Purpose of Vascular Surgery

Vascular surgery includes any type of surgical procedure involving the arteries, veins, or capillaries, which are all vessels that transport blood. Vascular surgery can be necessary to treat many different types of vascular disease, some of which are life-threatening. 

Often, to qualify for surgery, a person must have a vascular condition that does not respond well to lifestyle changes—such as diet, quitting smoking, and exercise—and other types of non-invasive treatment—like medication. 

Diagnosis Related to Vascular Surgery

In some instances, emergency vascular surgery—such as the repair of an aortic aneurysm—must be performed to save a person’s life; in yet other scenarios, vascular surgery is done to relieve pain and help improve the quality of life. 

Preventative measures are often incorporated when it comes to the purpose of vascular surgery. A good example is a common type of vascular procedure called a carotid endarterectomy, involving the removal of plaques—that occur due to atherosclerosis—from the carotid arteries, to prevent a stroke. Atherosclerosis, which used to be called hardening of the arteries, is a vascular condition involving plaques that adhere to the arteries, eventually occluding or narrowing the blood vessel and inhibiting proper blood flow.

Other conditions that often require vascular surgery include:

• Acute (severe/quick onset) deep vein thrombosis: These are also known as blood clots.
• Aortic aneurysms: This can occur in the chest (thoracic aortic aneurysm) or in the abdomen (abdominal aortic aneurysm).
• Critical limb ischemia: This is the loss of blood flow in the limbs, usually caused by peripheral artery disease (PAD). PAD is a condition involving the blockage of an artery that supplies blood to the legs, arms, head, or abdomen, usually caused by atherosclerosis.
• Diabetes vascular disease: The hardening of the arteries throughout the body, caused by diabetes, which can lead to the need for a limb salvage procedure.
• Dialysis graft and fistula management: A procedure aimed at creating venous access for dialysis.
• Non-healing wounds caused by vascular disease: Such as peripheral vascular disease (PVD), which is a blood circulation disorder involving the blockage or narrowing of any blood vessel outside of the heart and brain.
• Peripheral artery disease: When the arteries of the legs, arms, head, or abdomen become blocked or narrowed.
• Thoracic outlet syndrome: A condition that causes pain and numbness in the arms.
• Varicose veins: A condition involving weakening of the valves in the veins, usually occurs in the veins in the lower legs.
• Vascular malformations: Abnormal connections between blood and lymph vessels.
• Visceral artery disease: Diseased visceral arteries, which supply blood to the intestines, liver, and spleen.
• Lymphaticovenous anastomosis: A surgical procedure that connects a lymphatic vessel to a vein.

Vascular Surgery Classification

In addition to various types of vascular procedures, there are basically two classifications that describe surgical vascular treatment, these include: 

• Open surgery: Traditional surgery, which involves a long incision to provide a wide view and direct access to the vein, artery, or other vascular area. Open surgery is more invasive than endovascular surgery.
• Endovascular surgery: A minimally invasive procedure performed using long, thin tubes called catheters, which are inserted into the blood vessels through very small incisions in the skin. An example is an “endovascular stent graft procedure,” which is used to treat an aortic aneurysm. The graft is comprised of a special fabric tube device with self-expanding stents, which are inserted into the arteries (inside of a catheter), which is positioned inside the aorta. Once the graft is placed, it expands, sealing off the ballooned area (aneurysm) of the aorta. The graft remains in the aorta permanently. Minimally invasive procedures are associated with quicker recovery times and a lower risk of surgical complications.

In some complex vascular conditions, a combination of open and minimally invasive procedures are employed during the same operation.

Criteria

The criteria for any type of surgery involves a preset list of standards, which includes symptoms, specific lab values, and other diagnostic test results that must be met before a person is considered for a specific type of surgery. Of course, these standards change according to the type of surgery being considered. 

When it comes to vascular surgery, there are many types of procedures that are performed. But among the most common are aortic aneurysm repair, carotid endarterectomy, and bypass surgery, which is performed for deep vein thrombosis. The criteria for common types of vascular surgery include the preset parameters for conditions such as a blockage of the carotid artery, an aortic aneurysm, and bypass surgery for a blockage of a peripheral artery.

Carotid Endarterectomy

Why It's Done
There are several reasons that a carotid endarterectomy is done, including:

• A moderate (approximately 50 to 79%) blockage of a carotid artery along with symptoms of a stroke.
• A transient ischemic attack (TIA) that involves symptoms of a stroke such as speech or vision problems or numbness of the face that are temporary.
• A severe (80% or more) blockage of a carotid artery, with or without symptoms.

Criteria for a Carotid Endarterectomy
More specifically, according to the American Heart Association, the criteria for a carotid endarterectomy, for those who are considered a good surgical risk—which considers factors such as exercise tolerance and the existence of conditions such as angina and more—include:

• One or more TIA’s in the last 6 months and carotid stenosis (narrowing of the carotid artery) of more than 60%.
• Mild stroke within the last 6 months and carotid artery stenosis of over 60%.

It's important to note the criteria for having a carotid endarterectomy procedure fluctuates under certain circumstances, such as a person’s surgical risk and factors like the potential for acute rupture of an atherosclerotic plaque. Ruptured atherosclerotic plaques can release blood clots that can cause a fatal condition called acute coronary syndrome (ACS).

Abdominal Aortic Aneurysm Repair

Why It's Done
Reasons that may indicate that an abdominal aortic aneurysm repair is necessary include:

• Potential rupture of the abdominal aorta
• Blockage of blood flow through the abdominal aorta
• When the risk of a ruptured abdominal aneurysm is greater than any surgical risks posed by performing the procedure
• To repair bleeding that is considered an emergency, life-threatening situation
• To relieve symptoms such as deep, unrelenting pain or discomfort in the abdomen or back pain

Criteria for an Abdominal Aortic Aneurysm (AAA) Repair
A ruptured AAA is a fatal condition unless emergency surgery is performed immediately. Because of the high mortality (death) rate associated with ruptured aortic aneurysms—both abdominal aneurysms as well as thoracic aneurysms—the overall goal of treatment is to prevent ruptures. Criteria for surgical intervention, based on clinical research studies, include:

• The larger the AAA, the higher the risk of rupture.
• An AAA that measures over 2.16 inches (5.5 cm) in diameter
• An abdominal aneurysm that is growing more than 0.2 inches (0.5 cm) in a 12-month time span

Peripheral Artery Bypass

Why It's Done
Peripheral artery bypass surgery is performed to re-route the supply of blood to bypass the diseased or blocked artery; it's usually done because fatty deposits (called plaques) prohibited blood to flow to the extremities (usually the legs). You may need a peripheral artery bypass if you:

• Have skin ulcers (sores) or wounds that will not heal
• Your symptoms do not improve with other treatment modalities such as lifestyle changes, like smoking cessation or medication.
• Less invasive treatments such as stenting—a minimally invasive surgical procedure to place a stent in a vessel to keep in open—or angioplasty—a procedure aimed at repairing a diseased blood vessel—have not been successful.
• Your symptoms interfere with activities of daily living such as dressing or bathing.

Criteria for Peripheral Artery Bypass Surgery
The criteria for having peripheral artery bypass surgery differs according to the precise location (artery) that is blocked. The recommendation of whether to have open surgery or endovascular procedure also varies according to several different factors. It's important to talk to your surgeon or vascular specialist about your specific type of peripheral artery disease to find out what exactly the parameters are for having surgical treatment.

Tests and Labs

When it comes to tests and labs to decipher the need for vascular surgery, the vascular lab provides vital diagnostic tools. The type of exam/test performed in the vascular lab depends on what type of symptoms a person has. Some people have symptoms of vascular disease that develop very quickly and can be life-threatening such as those that are caused by a stroke, TIA, or blood clot. In other instances, symptoms have worsened slowly, over time, such as when narrowing of the arteries is caused by atherosclerosis. The vascular lab can help diagnose and assess the severity of vascular diseases and help surgeons and other specialists decide if and when surgery is needed.

Invasive vs Noninvasive Tests

Arteries and veins in the neck, arms, abdomen, and legs are assessed in the vascular lab; some studies rely on imaging techniques—such as ultrasound—and some do not.

Types of Noninvasive Testing

Non-imaging Tests
Non-imaging testing in the vascular lab may include procedures such as:

• Tests that compare pressure measurements.
• Tests that evaluate blood circulation in various vessels, including the small blood vessels (called capillaries) located in the fingers and toes.
• Ankle-brachial index (ABI), which utilizes several blood pressure cuffs placed on the arms and legs at various levels. The blood pressure and the blood flow volume are assessed at each level to help pinpoint the general location of a blockage in the arm or leg and decipher the severity of arterial disease. An ABI test can indicate that peripheral arterial disease is affecting the limbs, but it doesn't show, specifically, which blood vessels are blocked.

Imaging Tests
Imaging tests include those that utilize ultrasound to discover if vascular disease exists and to find the precise location and severity of vascular disease. Ultrasound can also be used to determine if circulation problems are new or preexisting. Imaging tests used to help evaluate whether a person needs vascular surgery include:

• Traditional ultrasound: This employs sound waves that bounce off of the tissues in the body to create images.
• Doppler ultrasound: This records sound waves that reflect off of moving objects. In the vascular lab, the moving object is blood, moving through the vessels. This information can be utilized to help measure the flow direction and speed that the blood is traveling, which is an indication of how severely blocked the blood vessel may be.
• Duplex ultrasound: This combines traditional ultrasound images with Doppler ultrasound. Duplex ultrasound is used to measure blood flow through the arteries and veins. The test is helpful in guiding your surgeon in formulating the best treatment plan for your vascular surgery.
• Intravascular ultrasound: This arteriogram (images taken after a dye is injected into the arteries) utilizes ultrasound cameras. The test is aimed at providing a road map of sorts for the surgeon to use during surgery. An intravascular ultrasound shows the exact type, location, and extent of the blockage.
• Magnetic resonance angiogram (MRA): A type of MRI that uses radio waves to take images of the blood vessels. It can show the severity of a blocked artery.

Purpose of Noninvasive Vascular Testing
Noninvasive vascular testing is often used to assess vascular conditions such as:

• Atherosclerosis
• Carotid artery disease
• Peripheral arterial disease (PAD)
• Renal artery stenosis (blockage of arteries to the kidney)
• Mesenteric artery disease (blockage of the arteries to the intestines)
• Aneurysm
• Conditions involving spasms of the blood vessels (such as Raynaud’s phenomenon)
• Trauma to an artery or vein
• Deep vein thrombosis (DVT)
• Varicose veins
• Ulcers (due to a condition called venous stasis)

A Word From Verywell

Vascular disease is common worldwide. In fact, according to a 2015 report, published by Circulation Research, over 200 million people worldwide have peripheral artery disease (PAD) and there may be many more cases of undiagnosed disease. In addition, emergencies resulting from vascular disorders represent a very high percentage; vascular diseases are linked with high morbidity (illness) and mortality (death) rates.

The good news is that because of the severity of many types of vascular disorders, coupled with the sheer number of people impacted by these diseases, there have been many recent advances in new treatment modalities. Perhaps one of the most important advances in medical treatment is minimally invasive therapies, which have translated to an increase in the number of people who undergo vascular disease treatment.